I need some advice. I just started a new position and I feel like every other OD that works there is faster than me at doing exams. I've tried so many things to become faster in the exam but I still seem to feel slow at it. The techs there also dilate the patients before I see them so that will hopefully speed up my exam time. Does anyone have any suggestions to speeding up the exam? Any refraction tips(I think this where I am the slowest)? Also, I think I may be going between doing the exam and typing data into the computer too much during the exam which could be slowing me down. I graduated last year so I know I can't possibly be super fast now but I just wanted to see how seasoned optometrists do their exams. Also, we schedule exams every 20 minutes. Thanks for any help!
Discouraged....
- Thread starter Eyes1984
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It's hard to be off much help not knowing exactly what setting you are in. Over the years I have managed to speed things up by using the concept of a problem oriented visit instead of giving everybody the same tests in a full comprehensive eye exam. Hang in there.
Record everything after the exam and focus on what matters. Any young person can speed up their times after a few months at the same place. I can't explain how I refract, but it involves a lot of comparisons of 0.50 D jumps and I generally trust the autorefractor cyl axis. I usually have an estimate before refracting that I push towards.
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Well ...
I try to keep the chit-chat short because that wastes time (though builds rapport).
Know where all your stuff is and have it in same room if possible.
Keep work area neat.
If you have a projector that allows you to only show 3 letters per line, do that. Block off unnecessary text on your near VA cards. Visual acuity actually slows me down the most because patients are so s ... l ... 0 ... w
Do all entrance testing on one swoop. Big E. Distance phoria, Near phoria with pen tip. Follow tip of pen for EOM. Cover left eye and do finger counting one quadrant at at time and do other eye. Then quick pupils.
Put in AR reading (if it's accurate). Otherwise put previous dx rx in phoropter.
With NEW patients, I do retinoscopy because I'm awesome at it and accurate at it and often it's my 7A (MR).
Find BCVA in phoropter with that "starting lens" and then do best sphere with that line. Then best cylinder not using the JCC. As a general rule, the cylinder should never exceed the cyl found by an autorefractor. Don't even bother testing for more cyl than the autorefractor finds because they tend to overestimate. True for 99% of people.
If you change cyl then recheck power.
Goto JCC at 20/40 if they are young. If older, do JCC at 20/50 to 20/70, line isolated.
I do power, axis. Sometimes power again. If they have .5 cyl power refine the axis using .75 and then take it out. That way they chase you around the axis less and is faster to find axis. If they have .25 cyl refine axis using .5 using same logic. Take out extra power when you have the axis. Saves time.
If they're a refractive monster and fast responder, you can do JCC faster using 20/30 line instead.
Then go back to sphere if you changed it a lot.
Last check is distance blur out to balance them and make sure not overminused. Add 3 Diopters plus to each eye. Block one off. Put up a 20/20 line (or their bcva). Then find the #7 or the first 20/20 when they can barely identify one or two letters. Do monocularly. Then open up both eyes when find that blur point and add .50D minus simultaneously. From that point, assuming you used 20/20 line, that should be the 7A or MR. At this point you should be done with refraction. If it's different from the first MR, before blur out, you can add .75D more minus at your own discretion. NO MORE than 1.00 more minus. That probably won't be tolerated.
Do distance h and v phorias for new patients to make sure they don't need prism.
Do near testing if there is a complaint or if they are over 40. I dial in what their add should roughly be according to age. Set my card at 17 inches for most people. If it's a little old lady - 14". Then at age "43" 1.25 Add "50" 1.50 Add "60" 2.00 Add "65+"2.50. Have then look at smallest line they can see and go for it. Don't fiddle-fart around. Once you think you have it, stop. That's your add. Then move on.
Not bragging, but I am a refracting animal like no other and I am accurate as heck. I've also been doing this forever. I like blur out refracting. Other docs like red-green refracting. Others like automation.
Then ask, "Do you mind if I dilate your eyes with the drops." Most say yes. Put them in. You don't really need to check angles if you're using 1% Tropicamide because I read a study that stated the probability of closing an angle using that mydiratic alone is almost zero. Now, it's different if you combine it with PE. If they are a new patient, I check angles quickly anyway, and only temporal one eye. The other should be the same! The other angle is almost always the same. And if they are existing patient and have been dilated before, just put drops in!
Give pt tissue. Put in prop. Tell them to blink ten times. As they do that unscrew lid to Tropic. Have pt dry eyes. Put them in. Have patient close eye. While patient is closing his eyes for a minute or 2, write out their rx, or do it in the emr. Type stuff in emr as they're sitting for a bit. Then have pt open eyes and look at frames before fully dilated.
In-between, start the next exam.
When I get them back I do slit-lamp bio. (I have neck problems and head mount gives me HA if use too much). Check primary posterior pole with 78 or 90, r and L. Record. Then switch to 120 D lens or 132D lens, back off mag w/slit lamp. Check all 8 quadrants. You can turn slit lamp at an angle when appropriate. Do one eye and record. Then do other eye and record.
And that should be it.
Oh, and if pt won't keep head in slit-lamp tell them to clench their teeth together tight (because it's usually due to them opening their mouths) and to rest the full weight of their head on the chin rest and to make sure forehead against forehead rest. Check as you go. They usu try to back off.
Also turn slit lamp illumination down. Usually minimal is all that is needed.
The part that will slow you down is the refraction, usually.
Anyway, this is a problem-focused approach and of course you modify as you see fit.
Hope this is helpful.
Also be aware of your movements and if you're standing and waiting for something, do something to remedy it. You should never be standing idle, basically.
I try to keep the chit-chat short because that wastes time (though builds rapport).
Know where all your stuff is and have it in same room if possible.
Keep work area neat.
If you have a projector that allows you to only show 3 letters per line, do that. Block off unnecessary text on your near VA cards. Visual acuity actually slows me down the most because patients are so s ... l ... 0 ... w
Do all entrance testing on one swoop. Big E. Distance phoria, Near phoria with pen tip. Follow tip of pen for EOM. Cover left eye and do finger counting one quadrant at at time and do other eye. Then quick pupils.
Put in AR reading (if it's accurate). Otherwise put previous dx rx in phoropter.
With NEW patients, I do retinoscopy because I'm awesome at it and accurate at it and often it's my 7A (MR).
Find BCVA in phoropter with that "starting lens" and then do best sphere with that line. Then best cylinder not using the JCC. As a general rule, the cylinder should never exceed the cyl found by an autorefractor. Don't even bother testing for more cyl than the autorefractor finds because they tend to overestimate. True for 99% of people.
If you change cyl then recheck power.
Goto JCC at 20/40 if they are young. If older, do JCC at 20/50 to 20/70, line isolated.
I do power, axis. Sometimes power again. If they have .5 cyl power refine the axis using .75 and then take it out. That way they chase you around the axis less and is faster to find axis. If they have .25 cyl refine axis using .5 using same logic. Take out extra power when you have the axis. Saves time.
If they're a refractive monster and fast responder, you can do JCC faster using 20/30 line instead.
Then go back to sphere if you changed it a lot.
Last check is distance blur out to balance them and make sure not overminused. Add 3 Diopters plus to each eye. Block one off. Put up a 20/20 line (or their bcva). Then find the #7 or the first 20/20 when they can barely identify one or two letters. Do monocularly. Then open up both eyes when find that blur point and add .50D minus simultaneously. From that point, assuming you used 20/20 line, that should be the 7A or MR. At this point you should be done with refraction. If it's different from the first MR, before blur out, you can add .75D more minus at your own discretion. NO MORE than 1.00 more minus. That probably won't be tolerated.
Do distance h and v phorias for new patients to make sure they don't need prism.
Do near testing if there is a complaint or if they are over 40. I dial in what their add should roughly be according to age. Set my card at 17 inches for most people. If it's a little old lady - 14". Then at age "43" 1.25 Add "50" 1.50 Add "60" 2.00 Add "65+"2.50. Have then look at smallest line they can see and go for it. Don't fiddle-fart around. Once you think you have it, stop. That's your add. Then move on.
Not bragging, but I am a refracting animal like no other and I am accurate as heck. I've also been doing this forever. I like blur out refracting. Other docs like red-green refracting. Others like automation.
Then ask, "Do you mind if I dilate your eyes with the drops." Most say yes. Put them in. You don't really need to check angles if you're using 1% Tropicamide because I read a study that stated the probability of closing an angle using that mydiratic alone is almost zero. Now, it's different if you combine it with PE. If they are a new patient, I check angles quickly anyway, and only temporal one eye. The other should be the same! The other angle is almost always the same. And if they are existing patient and have been dilated before, just put drops in!
Give pt tissue. Put in prop. Tell them to blink ten times. As they do that unscrew lid to Tropic. Have pt dry eyes. Put them in. Have patient close eye. While patient is closing his eyes for a minute or 2, write out their rx, or do it in the emr. Type stuff in emr as they're sitting for a bit. Then have pt open eyes and look at frames before fully dilated.
In-between, start the next exam.
When I get them back I do slit-lamp bio. (I have neck problems and head mount gives me HA if use too much). Check primary posterior pole with 78 or 90, r and L. Record. Then switch to 120 D lens or 132D lens, back off mag w/slit lamp. Check all 8 quadrants. You can turn slit lamp at an angle when appropriate. Do one eye and record. Then do other eye and record.
And that should be it.
Oh, and if pt won't keep head in slit-lamp tell them to clench their teeth together tight (because it's usually due to them opening their mouths) and to rest the full weight of their head on the chin rest and to make sure forehead against forehead rest. Check as you go. They usu try to back off.
Also turn slit lamp illumination down. Usually minimal is all that is needed.
The part that will slow you down is the refraction, usually.
Anyway, this is a problem-focused approach and of course you modify as you see fit.
Hope this is helpful.
Also be aware of your movements and if you're standing and waiting for something, do something to remedy it. You should never be standing idle, basically.
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