Scope of practice opinions...

[posner]

Keep up the good work Posner! I just want to contribute by saying that I have also seen both types of OMDs. Though, I dont agree with all of your "characterizations" regarding ophthalmology, the simple fact is that you can get bad kinds of any doctors (as you clearly inferred). My daily anecdote includes a new pt with heavy duty nipple kcone (88ks and around 300 microns) BCVA OS 20/200, PKP OD BCVA 20/200 (no cl), recently lost RGP OS. Basically on the verge of PKP OS (topo is off the hook). Desperate about his VA, even though I just started with a diagnostic lens (plano). Pt calls "old" OD (who hasnt examined pt in almost two years) places order for cl over the phone and voila! a new cl in the mail! WTF is that about?! So the door swings both ways thats for sure.

Im in a small town practice and have "decent" relationships with retina, cataract, etc. I admit to not being as diligent in following up with referred "out" patients (as far as know I see "most" of them back) , although I do a pretty good job with referred "in" patients. Ive heard this before and it represents great insight, so thank you for reminding me to get off my ass.

Again, I would like to state that I personally have a very good relationship with the OMDs in my community. Most of my characterizations of OMDs do not apply any of the OMDs I currently work with. These characterizations refer in large part to the OMDs I have come into contact with on this board in addition to a few I have met along the way.

Posner

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[KHE]

I do however, routinely scleral depress, probe/dilate/irrigate, etc. I appreciate you taking me to task(or defending those who have appropriately done so); it is my ultimate intention to foster constructive discussions on ways to provide better patient care.

You need to be more precise in your postings. These are claims that you have made:

Just out of curiosity, do you throw a gonio lens on every patient before you dilate? If you do, you are the exception. I see 25-35 patients a day(80% of whom I dilate) and while I do grossly assess angles prior to dilating, I dont use a gonio lens unless specifically indicated.

You make a good point(in spite of your efforts to be a giant dick). I dilate EVERY patient that I see(25-30 per day) and I am sure to look to the best of my ability. I send a complete letter of my findings to the patients PCP or OMD specialist if they see one.

Both of these quotes are from you. On one hand, you claim to dilate EVERY patient you see, and on the other you claim to dilate 80%. Which is it?

THe OMDs want to be in the OR as much as possible. They appreciate the 70-80 CE/IOL patients my office sends them each month along with the LASIK patients.

You know what I love more? The fact that they need me and my practices more than I need them We could send our 40-50 CE/IOL patients per month, multiple LASIK patients, countless retina cases, etc to anyone and they know it.

Again, on one hand you are claiming to send 70-80 CEs a month and on the other 40-50. Which one is it? Either way, most cataract practices do not generate that kind of volume, and yet an optometric practice generates that many cataract patients for surgery? Hmmmmm.

You're going to need to clarify your postings.

 

[posner]

You need to be more precise in your postings. These are claims that you have made:





Both of these quotes are from you. On one hand, you claim to dilate EVERY patient you see, and on the other you claim to dilate 80%. Which is it?





Again, on one hand you are claiming to send 70-80 CEs a month and on the other 40-50. Which one is it? Either way, most cataract practices do not generate that kind of volume, and yet an optometric practice generates that many cataract patients for surgery? Hmmmmm.

You're going to need to clarify your postings.

Without a doubt, every single patient I see gets at least a drop of paramyd. Many would argue this is not sufficient for true dilation(and I would agree) therefore I use the regular myd and phenyl on patients that require true dilation(about 75-80% of my patients).

As for catarct referrals, we sent out 59 for the month of November. There are four ODs in our corporation and each of us sees between 17-30+ patients per day. We certainly have a slightly older patient base(my partner and associates since they are 15+years older than I am, have a much older patient base). Of the more than 1200-1500 patients our corporation sees each month(depending on the month), it doesnt seem odd to me that we have a number of CE referrals(4-5%). For your reference, our volume routinely puts us among the top 1-5% of all practices nationwide in several areas(data that is sent to us from our buying group(s)). I am sorry if I wasnt clearer in my earlier posts. I think the idea was to foster discussion(you will note my posts have been the center of much discussion- you can find this out if you should want to nit pick every detail of my history/posting further).

I have nothing to prove to any of you on this board. I dont care if you come see my home or my cars or any of that meaningless BS. Whether you fail as an OD doesnt keep me awake at night in the least. I am very content with what I have done so far in the profession. If I can start or add to discussions that may lead to something positive for others than great. If not, than I can simply state my opinion and move on.

I hope I was able to clarify some things for you. Please let me know if I can be of further assistance in your data verification process. For the record, I sent out two CEs and one Lasik patient this morning alone(and there are 3 more of us in the same practice seeing patients)

Posner

 

[posner]

Just for fun I decided to go back from June and see how many CE patients we have been referring out for your spreadsheets. Here are the numbers for your perusal:

June: 31(I dont know what happened here?)
July: 46
August: 42
September:55
October: 51
November: 59

Our biggest month this year has been March and we sent out 68 patients for CE/IOL. So I stand corrected in that 70-80 CE/IOL patients in a month is not the norm for us, but rather an apparent exaggeration. I would, however, maintain that we have a large volume of cataract referrals.

Posner

 

[docvisionX]

You need to be more precise in your postings. These are claims that you have made:





Both of these quotes are from you. On one hand, you claim to dilate EVERY patient you see, and on the other you claim to dilate 80%. Which is it?





Again, on one hand you are claiming to send 70-80 CEs a month and on the other 40-50. Which one is it? Either way, most cataract practices do not generate that kind of volume, and yet an optometric practice generates that many cataract patients for surgery? Hmmmmm.

You're going to need to clarify your postings.

Posner shares the secrets to his success on these forums when he could be out on the central coast slumped in a lazy chair with a nice bottle of Grey Goose deciding whether or not he feels more like scuba diving in Bora Bora or purchasing investment property outside of Monterey over the weekend------and for his time he is rewarded these types of rediculous responses.

Read through his posts--they are full of valuable points and strategies. He has succeeded where most of the pessimistic contributors to this forum have obviously failed. I mean, come on people, docs pay practice consultants big money for some of the information he has shared in all of his posts.

I, for one, as an up-and-coming eye doc, am taking huge advantage of the information he as thrown out. Perhaps, instead of disputing how he operates his practice, take note and strive for the same success.

I rarely post in the forum, but clearly you see why.

 

[posner]

Posner shares the secrets to his success on these forums when he could be out on the central coast slumped in a lazy chair with a nice bottle of Grey Goose deciding whether or not he feels more like scuba diving in Bora Bora or purchasing investment property outside of Monterey over the weekend------and for his time he is rewarded these types of rediculous responses.

Read through his posts--they are full of valuable points and strategies. He has succeeded where most of the pessimistic contributors to this forum have obviously failed. I mean, come on people, docs pay practice consultants big money for some of the information he has shared in all of his posts.

I, for one, as an up-and-coming eye doc, am taking huge advantage of the information he as thrown out. Perhaps, instead of disputing how he operates his practice, take note and strive for the same success.

I rarely post in the forum, but clearly you see why.

While I appreciate your support, I certainly dont spend my free time deciding where to vacation or how to buy more investment property. With a new home and another child on the way, I mind my business often; I cant afford not to be successful.

By the way, if you get the chance be sure to take a giant dump on Les Walls' desk before he steps down. Tell him posner sends his very best.

Posner

 

[docvisionX]

LOL!!! Will do.

 

[KHE]

Read through his posts--they are full of valuable points and strategies. He has succeeded where most of the pessimistic contributors to this forum have obviously failed. I mean, come on people, docs pay practice consultants big money for some of the information he has shared in all of his posts.

I, for one, as an up-and-coming eye doc, am taking huge advantage of the information he as thrown out. Perhaps, instead of disputing how he operates his practice, take note and strive for the same success.

If I paid a consultant big money and ended up with a practice like posner's, I'd demand my money back.

From his own numbers:

He claims in a thread titled "My rant on the current state of optometry" that his practice is on target to gross 2.1 million this year.

We should do about $2.1 mil this year between our offices(this is revenue not charges). I have one partner and myself and we are 50/50.

In this very thread he claims that his corporation sees between 1200 and 1500 patients per month.

If that's the case, that means that he is grossing between $146 per patient (1200 per month) and $117 per patient (1500 per month)

That's WAY below the national average of gross per patient even for the worst performing optometric practices.

Dr. Chudner and I have pointed out a large number of inconsistencies in his postings. His posts are full of bluster and bravado but his own postings don't match all the bluster. Dr. Chudner and I are not the only ones skeptical of his claims. Two other doctors who have successful practices and regularly post on these forums have also emailed me privately doubting his claims. I won't speak for them, they can post publicly their concerns if they wish but students should know that many of the seasoned doctors on this forum have serious doubts of Dr. Posners claims and these concerns are NOT coming from doctors who are negative on optometry. They are coming from seasoned practitioners with successful (over a million dollar) practices.

 

[posner]

If I paid a consultant big money and ended up with a practice like posner's, I'd demand my money back.

From his own numbers:

He claims in a thread titled "My rant on the current state of optometry" that his practice is on target to gross 2.1 million this year.



In this very thread he claims that his corporation sees between 1200 and 1500 patients per month.

If that's the case, that means that he is grossing between $146 per patient (1200 per month) and $117 per patient (1500 per month)

That's WAY below the national average of gross per patient even for the worst performing optometric practices.

Dr. Chudner and I have pointed out a large number of inconsistencies in his postings. His posts are full of bluster and bravado but his own postings don't match all the bluster. Dr. Chudner and I are not the only ones skeptical of his claims. Two other doctors who have successful practices and regularly post on these forums have also emailed me privately doubting his claims. I won't speak for them, they can post publicly their concerns if they wish but students should know that many of the seasoned doctors on this forum have serious doubts of Dr. Posners claims and these concerns are NOT coming from doctors who are negative on optometry. They are coming from seasoned practitioners with successful (over a million dollar) practices.

nevermind

 

[POJO]

KHE, Posner, et. al,

Ok, this is supposed to be about scope of practice rather than who makes more $$. I don't believe that it helps that this thread direction is more about "bluster" vs. reality. Come on doctors. This doesn't serve the "students".

Let's get back to the thread at hand.

 

[posner]

KHE, Posner, et. al,

Ok, this is supposed to be about scope of practice rather than who makes more $$. I don't believe that it helps that this thread direction is more about "bluster" vs. reality. Come on doctors. This doesn't serve the "students".

Let's get back to the thread at hand.

My apologies. From this point forward I will endeavor not to discuss the financial aspects of my practice. I will gladly discuss these matters in private should anyone be interested or if they feel it will help them in their pursuits. I wont mention any names, but one of the docs on this board is scheduled to come visit my practice(we are taking on a new associate next summer) just after the first of the year. I will let him speak about what he finds when he visits. Perhaps then KHE and Ben can get back to discussions that REALLY matter instead of questioning the validity of my posts.

Posner

 

[posner]

I would love to know what the national average revenue per patient is for my own edification. I know that some would suggest it is $250-300 or more. I may generate $500 on a pair of glasses, but if I have $250 wrapped up in materials and the cost of employing 4 opticians in our big office, what have I really made? Not to mention the man power it takes to work these patients up so that I can go spend 10-12 minutes in a room. As I have mentioned before, we earn the majority of our income from the services end of the business but we benefit from our office being so busy and having a nice dispensary to capture many of our patients without having to really push glasses.

Also for additional clarification, I should have said that we have 1200-1500 slots in our appointment schedule each month. I dont know exactly how many of these patients we see for contact lens related problems under our service agreement(flat fee annually) or how many of these patients are follow ups, etc. I would love tips on being more efficient. I have said previously that we are inefficient, but KHE in his last post has really got me thinking. THe senior partner(began the practice cold in 1977) is a well known contact lens expert. He still sees new fits at 1 week, 2-3 weeks, 4-6 weeks, and every 4-6 months thereafter. He has long time cl wearing patients that come back 3 times per year(usually part of his annual service agreement). I have tried to discontinue this practice but the staff and some of the patients feel like you are trying to pull one over on them even though I feel as though it is a waste of chair time. Any thoughts?


Posner

 

[PBEA]

I would love to know what the national average revenue per patient is for my own edification. I know that some would suggest it is $250-300 or more. I may generate $500 on a pair of glasses, but if I have $250 wrapped up in materials and the cost of employing 4 opticians in our big office, what have I really made? Not to mention the man power it takes to work these patients up so that I can go spend 10-12 minutes in a room. As I have mentioned before, we earn the majority of our income from the services end of the business but we benefit from our office being so busy and having a nice dispensary to capture many of our patients without having to really push glasses.

Also for additional clarification, I should have said that we have 1200-1500 slots in our appointment schedule each month. I dont know exactly how many of these patients we see for contact lens related problems under our service agreement(flat fee annually) or how many of these patients are follow ups, etc. I would love tips on being more efficient. I have said previously that we are inefficient, but KHE in his last post has really got me thinking. THe senior partner(began the practice cold in 1977) is a well known contact lens expert. He still sees new fits at 1 week, 2-3 weeks, 4-6 weeks, and every 4-6 months thereafter. He has long time cl wearing patients that come back 3 times per year(usually part of his annual service agreement). I have tried to discontinue this practice but the staff and some of the patients feel like you are trying to pull one over on them even though I feel as though it is a waste of chair time. Any thoughts?


Posner

OOOOOH, I think you might actually touch off a nerve or two, with that last comment about your partner! Me personally, I would like to take a spade and shovel so I can bury the legacy of "free" re-refractions that my predecessors (and current corporate "colleagues") have laid for me. For this reason, I cant understand why ANY OMD would want to embroil themself into the mire of spectacle dispensing. Just a note for you students, many eye conditions produce unstable and variable endpoints for refraction. That being the case, do you think that you should be responsible for the cost of refabricating that spectacle Rx? This is definitely a question you should debate, because to me it points to the core of "traditional" optometry (which is often unable to discern EBMD from a Big Mac) and how it can sometimes conflict with reality.

 

[PBEA]

I would love to know what the national average revenue per patient is for my own edification. I know that some would suggest it is $250-300 or more. I may generate $500 on a pair of glasses, but if I have $250 wrapped up in materials and the cost of employing 4 opticians in our big office, what have I really made? Not to mention the man power it takes to work these patients up so that I can go spend 10-12 minutes in a room. As I have mentioned before, we earn the majority of our income from the services end of the business but we benefit from our office being so busy and having a nice dispensary to capture many of our patients without having to really push glasses.

Also for additional clarification, I should have said that we have 1200-1500 slots in our appointment schedule each month. I dont know exactly how many of these patients we see for contact lens related problems under our service agreement(flat fee annually) or how many of these patients are follow ups, etc. I would love tips on being more efficient. I have said previously that we are inefficient, but KHE in his last post has really got me thinking. THe senior partner(began the practice cold in 1977) is a well known contact lens expert. He still sees new fits at 1 week, 2-3 weeks, 4-6 weeks, and every 4-6 months thereafter. He has long time cl wearing patients that come back 3 times per year(usually part of his annual service agreement). I have tried to discontinue this practice but the staff and some of the patients feel like you are trying to pull one over on them even though I feel as though it is a waste of chair time. Any thoughts?


Posner

Oh, and offhand I dont know my exact numbers but we defintely are not avg$250, more in your realm of $150, which I think reflects a heavier managed care environment then many are exposed to. Im a small practice and while I consider myself pretty efficient, I am mostly billing insurance for my services, so I dont see the immediate return on my charges. Effiency helps but is not the only answer to success (now thats personal). With your volume it sounds like less of an issue, but in my small office (or any small office?), it can be difficult to maintain solvency.

 

[Ben Chudner]

My apologies. From this point forward I will endeavor not to discuss the financial aspects of my practice. I will gladly discuss these matters in private should anyone be interested or if they feel it will help them in their pursuits. I wont mention any names, but one of the docs on this board is scheduled to come visit my practice(we are taking on a new associate next summer) just after the first of the year. I will let him speak about what he finds when he visits. Perhaps then KHE and Ben can get back to discussions that REALLY matter instead of questioning the validity of my posts.

Posner

I believe the validity of posts is a discussion that does really matter. I am always skeptical of posts on an anonymous forum and I think the point of bringing this up is to remind students that on sites such as these, you have to take everything with a grain of salt. I have no idea who Posner is, nor do I have any idea how successful his practice is. Deep down I hope he is even more successful than his posts imply. I think it is important for the profession for private practices to continue to grow. I had a discussion about his posts with KHE because as an owner of a private practice, some of what he was saying did not make sense to me and I did not expect a student to be able to see that. At the end of the day, however, it does not matter what I, or anyone else believes.

 

[PDT4CNV]

In private practice, I do not perform these procedures as they are currently outside my scope of practice. Also, I do not believe the scope of practice for optometry should include pterygium removal(again I have said this several times previously). I do think there should be some allowance for superficial/mildly/non invasive lid lesion excision/biopsy and a few other things, however.

My neighbor is a local plactic surgeon and she says her best patients are those that have had botched blephs(lowers and uppers) with local OMDs. It goes on and on.


Posner

I'm glad to hear you do not do this in private practice. Excision or biopsy of skin lesions anywhere on the body, including the eyelids, contitutes a surgical procedure and is not within optometry scope of practice.

Regarding your neighbor, remember who your talking to. Believe me, ophthalmologists see their own fair share of "botched" blephs from the general plastics guys. The average general plastics surgery resident will have done 6-10 blepharoplasties while in training. Any ophthalmologist who trained anywhere decent will have done far more than that. The numberes are a bit better for the fellowship trained facial plastic guys. The fellowship trained oculoplastics guys I would say are by far the best lid surgeons.

Regarding botox, Read up on the history of botox. I think you would be suprised to learn what specialty of medicine has been using botox for a very long time.

I agree that retinal procedures should be referred to fellowship trained guys by most general ophthalmologists. Some old school comprehensive guys do buckles and have been doing buckles for years. Trabs, PK's, refractive surgery, and lid surgery are well within the scope of practice of the comprehensive ophthalmologists.

Now, if you haven't done a trab in 10 years, well, that's a different story. Good judgement is always paramount.

Whether or not your local ophthalmologists are good surgeons I cannot comment on other than to say that this has no bearing on scope of practice policy as surgeons vary in skill in every surgical specialty.

 

[hye345]

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