Why is it so degrading for optometrists to work at Wal-mart?

[Bob_Barker27]

I don't remember aiming my comment specifically at anyone. I'm not telling anyone to quit debating. I'm just saying people are reading into other people's posts, people are getting defensive, and it's getting ugly. So, i'm trying to put a stop to it and calm it down. (that's my job)

I did ask my friend about dilation at wal-mart. she was never told not to do it.

Hey cpw,

You are right, you didn't aim your comment specifically at anyone. You aimed it specifically at everybody, which includes me. I'm just giving you a hard time. I think I remember an optometrist who posted in here a month ago or so saying he did dilations at wal-mart too when some others were belittling him for working there, and I believe Jenny said she did them in a corporate setting as well, so that that gives us a total of 3 with your friend included. I'm going to go out on a limb and conclude that walmart doesn't prohibit dilations as part of corporate policy based on this evidence. From what I gather, the worse things about working at Walmart are:
1. Often have to work a lot of hours (this can be a problem at any job where you work for someone else).
2. Optometrists feel less doctorly working in a big retail store and fear the general public does not respect them as doctors in this type of setting (this may be true, but it seems enough to respect walmart optometrists to keep them in business, and an optometrist might have self esteem problems if he or she is overly concerned with public perception. As long as you perform the same tasks that other optometrists do, i'm not sure it matters if it feels doctorly or not. I worked in a trailer as a mechanical engineer, but the pay was the same as working in nice dowtown office, so I could care less).
3. Some optometrists don't want to tell friends he works at Wal-mart because it may seem less prestigious (just personal vanity).
4. Walmart may have less equipment that could limit the scope of practice. (This could make practice at walmart less interesting, but doesn't seem to force the optometrists to practice in an unethical manner and the equipment walmart provides probably allows diagnosis of most types of eye diseases and problems. It seems to me the optometrist at walmart could purchase himself
other equipment if he or she wanted to expand the services they offer.)
5. Having to park your car in the Wal-mart parking lot. (Dodging all those shopping carts can get dicey)

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[PBEA]

That's very interesting. You've had 3 cases at a Walmart in 6 months that were a threat to life or sight, and I've had 3 cases in over 10 years, a significant amount of time having been spent in a VA. You have a strange patient population. What was the nature of these 20 conditions? Or the 3 at Walmart if you don't mind sharing??

Jenny

How bout I just tell you about the person I saw in the last 3 months (without violating any HIPAA constraints ). This new 38yo wm was positive that one upper lid had started to droop and that the vision was perfect, VAsc 20/50 ou, BCVA 20/20- ou. no ptosis noted. No other history, cept maybe mom had "cataracts", never wore glasses, never had "such a thorough exam" (I laugh when I hear this because typically they don't know any better). Funny (or not so funny) thing is, I hear that comment quite often, and it almost always relates to dilation. No external or anterior signs. Is the standard of care sufficient in this case?

 

[JennyW]

How bout I just tell you about the person I saw in the last 3 months (without violating any HIPAA constraints ). This new 38yo wm was positive that one upper lid had started to droop and that the vision was perfect, VAsc 20/50 ou, BCVA 20/20- ou. no ptosis noted. No other history, cept maybe mom had "cataracts", never wore glasses, never had "such a thorough exam" (I laugh when I hear this because typically they don't know any better). Funny (or not so funny) thing is, I hear that comment quite often, and it almost always relates to dilation. No external or anterior signs. Is the standard of care sufficient in this case?

How would you discussing these vision or life threatening cases that you have seen be a HIPPA violation?? I'm not asking you to identify the patients. Just tell us what conditions you are finding in young asymptomatic patients that are vision and life threatening.

The patient you discuss in this case is NOT asymptomatic.

You ask "is the standard of care sufficient in this case?" What do you think the standard of care would be for a case like this? What possible disease process could you find on dilation that would cause a "droopy eyelid?"

Jenny

 

[meb302]

Man o man, all this bickering! Can't we all just be friends!!!

 

[Tom_Stickel]

Hey cpw,

5. Having to park your car in the Wal-mart parking lot. (Dodging all those shopping carts can get dicey)

Bob,
I have 3 big dents in my car from the Sam's Club parking lot And I always parked a long way from the door away from other cars...
The big drawback to parking a long way from the other cars is that Sam's Club pays you in cash at the end of every day. Walking out of a Sam's Club at 8:30 at night in a sketchy neighborhood with $500 cash in your pocket will get your sympathetic nervous system working...

Tom

 

[cpw]

Bob,
I have 3 big dents in my car from the Sam's Club parking lot And I always parked a long way from the door away from other cars...
The big drawback to parking a long way from the other cars is that Sam's Club pays you in cash at the end of every day. Walking out of a Sam's Club at 8:30 at night in a sketchy neighborhood with $500 cash in your pocket will get your sympathetic nervous system working...

Tom

ooo that would be nerve wracking. But oooo cash. Although I'm bad with cash.. as soon as my wallet sees cash my brain goes. "fun money!!" I'd have to get over that real quick working there.

 

[PBEA]

How would you discussing these vision or life threatening cases that you have seen be a HIPPA violation?? I'm not asking you to identify the patients. Just tell us what conditions you are finding in young asymptomatic patients that are vision and life threatening.

The patient you discuss in this case is NOT asymptomatic.

You ask "is the standard of care sufficient in this case?" What do you think the standard of care would be for a case like this? What possible disease process could you find on dilation that would cause a "droopy eyelid?"

Jenny

I was trying to be funny when I said HIPAA contraints, I guess it was not that funny. Altogether you seem overly defensive to the point of anger. I think that we disagree, but I happen to think both sides of this discussion (or argument in your case) have merits. You, on the other hand, vehemently disagree with everything I have said. No point in wasting my time presenting any more of these cases to you, because I can feel your sarcasm oozing through the internet, and quite frankly it is unwarranted. Oh, and the person I was trying to discuss had about 20 percent of their retina detached, superiorly (ie, droopy lid). For the record, standards of care are general guidelines and represent the minimum requirement. It's my opinion that going above these standards is not only commonplace, but our responsibility.

 

[PBEA]

If you don't want to work for "a large capitalist corporation" like walmart, don't go work for them. If you work as an optometrist, you yourself are engaging in capitalism, and i bet you are going to care about the bottom line yourself. If making money is evil, then there sure are a lot of evil people in the world. Walmart does't exist to save the world and "be concerned with John Q Public", it exists to make money, and nobody forces you to shop there or work there. Wal-mart does provide low prices, and I know it's tough for you to admit this, but that benefits John Q Public. It seems to me that there must be a lot of unethical optometrists out there, if so many are willing to work for Walmart when it's true as you claim that Wal-mart does not allow optometrists to practice in an ethical manner. Maybe you should be attacking the optometrists that choose to practice in an unethical manner at Walmart, not Walmart. Maybe if optometrists all refused to work at wal-marts, walmart would consider changing their evil ways. Your Fox News comment was a little bizarre and out of place, but in defense of Fox News, they are the #1 cable news channel in America, and I don't think that would be case if Fox News wasn't a solid source of information. Fox News sucess is directly proportional to the liberal bias of the other news networks. See Dan Rather's use of forged memos to hurt a Republican's presidents re-election chances. I could say you are one of these people that gets his information from Michael Moore. I think Fox News is a litle more trustworthy than Michael Moore.

I should not have used "capitalist" in my description. As a business, I think it is totally justified that walmart maintains its bottom line. However, when any individual, or entity, engages in delivering healthcare, I believe that they must deliver it responsibly. This resposibility can NOT play second fiddle to any concerns about how much money is being made. Throughout much of our nations healthcare this might not be the problem, but if there is a scenario when certain diagnostic procedures are not being performed because it takes to long, or not enough money is being made, then I suggest that this is inappropriate. I do not suggest that ALL OD's in walmart don't dilate, I can only relay my own experience with walmart.

Oh, and Fox "news" as you call it, is not a real TV station. It is blatant propaganda (that should get your pilot lit). Although, I do enjoy their NFL pregame.

 

[JennyW]

I was trying to be funny when I said HIPAA contraints, I guess it was not that funny. Altogether you seem overly defensive to the point of anger. I think that we disagree, but I happen to think both sides of this discussion (or argument in your case) have merits. You, on the other hand, vehemently disagree with everything I have said. No point in wasting my time presenting any more of these cases to you, because I can feel your sarcasm oozing through the internet, and quite frankly it is unwarranted. Oh, and the person I was trying to discuss had about 20 percent of their retina detached, superiorly (ie, droopy lid). For the record, standards of care are general guidelines and represent the minimum requirement. It's my opinion that going above these standards is not only commonplace, but our responsibility.

You're completely wrong. I have not been sarcastic, and I've not "vehemently" disagreed with anything you have said. I disagree with your point that if a person is not dilated and they have a condition that could have been detected through dilation that the doctor is automatically culpable. That's it. I have no idea where you are getting this idea of sarcasm.

I am trying to find out the types of cases that you are seeing because you are claiming that you are seeing all sorts of sight and life threatening conditions that you are picking up through routine dilation and I've seen so very few. I don't understand your resistance to share what these disease entities were.

Jenny

BTW: A patient with a superior retinal detachment would have an inferior defect. Where is this "droopy eyelid" coming from??

 

[Richard_Hom]

Dear Forum,

The notion of routine dilation is something that has garnered much discussion amongst optometrists for many years ever since optometrists have been held civilly liable for failure to diagnose or failure to use the means necessary to diagnose.

I believe the practice of routine dilation is a mixture of a) Custom b) Risk aversion and D) Risk Management. For doctors who do it routinely, it is part of their workflow and it takes too much effort to discriminate when or when not to dilate someone. "Dilate them all" is a common custom and simplifies the workflow especially if ancillary help is used.

Many optometrists still have a workflow of one examination room. If you think of manufacturing that the has only one place to assemble things, then things happen one at a time. You can move the person out of the place and place another person there, but it is much easier to move the assembler and in this case the doctor from place to place. If everyone is dilated then the doctor can immediately pick the BIO and look in. There is no hesitation to look to see if it is dilated or not. It has been done.

In regards to yield, there will always be anecdotal evidence given that prompts doctors to dilate everyone. But in reality, the yield is miniscule in asymptomatic 'normal' patients. Therefore, even the largest HMO in the country doesn't dilate everyone routinely.

I think it all depends upon your patient population. If a doctor in whatever environment feels that the patient population is high risk, then of course they would dilate. Alternatively, I believe that many wouldn not if the patient population is perceived to be low riskl

Absolutes are never good guides. I don't support "all the time" nor "never". If you can explain your risk profile, your patient population risk profile, then it is quite understandable why you would do something or not. On the other hand, optometrists should also openly admit that dilating everybody may be as important to the doctor in their self-esteem as it is for the patient.

IMHO of course,
Richard

 

[cpw]

BTW: A patient with a superior retinal detachment would have an inferior defect. Where is this "droopy eyelid" coming from??

that's what i was wondering, too, Jenny. was is really an inferior detachment ??

 

[cpw]

Dear Forum,

The notion of routine dilation is something that has garnered much discussion amongst optometrists for many years ever since optometrists have been held civilly liable for failure to diagnose or failure to use the means necessary to diagnose.

I believe the practice of routine dilation is a mixture of a) Custom b) Risk aversion and D) Risk Management. For doctors who do it routinely, it is part of their workflow and it takes too much effort to discriminate when or when not to dilate someone. "Dilate them all" is a common custom and simplifies the workflow especially if ancillary help is used.

Many optometrists still have a workflow of one examination room. If you think of manufacturing that the has only one place to assemble things, then things happen one at a time. You can move the person out of the place and place another person there, but it is much easier to move the assembler and in this case the doctor from place to place. If everyone is dilated then the doctor can immediately pick the BIO and look in. There is no hesitation to look to see if it is dilated or not. It has been done.

In regards to yield, there will always be anecdotal evidence given that prompts doctors to dilate everyone. But in reality, the yield is miniscule in asymptomatic 'normal' patients. Therefore, even the largest HMO in the country doesn't dilate everyone routinely.

I think it all depends upon your patient population. If a doctor in whatever environment feels that the patient population is high risk, then of course they would dilate. Alternatively, I believe that many wouldn not if the patient population is perceived to be low riskl

Absolutes are never good guides. I don't support "all the time" nor "never". If you can explain your risk profile, your patient population risk profile, then it is quite understandable why you would do something or not. On the other hand, optometrists should also openly admit that dilating everybody may be as important to the doctor in their self-esteem as it is for the patient.

IMHO of course,
Richard

well said, Dr Hom. I find a lot of times after I explain why we dilate patients most patients want it done.

 

[PBEA]

that's what i was wondering, too, Jenny. was is really an inferior detachment ??

cpw-it was superior detachment. I did not do a visual field to confirm an inferior defect, counting fingers revealed no defect, and that isn't the point. Either this pt was unable to accurately articulate the symptom, or their were'nt any symptoms related to a retinal detachment. I did a ROUTINE dilation, as the pt was new to the office. Needless to say there was nothing wrong with the eyelid.

 

[cpw]

cpw-it was superior detachment. I did not do a visual field to confirm an inferior defect, counting fingers revealed no defect, and that isn't the point. Either this pt was unable to accurately articulate the symptom, or their were'nt any symptoms related to a retinal detachment. I did a ROUTINE dilation, as the pt was new to the office. Needless to say there was nothing wrong with the eyelid.

I was just curious. No need to get defensive. It sounds like a great case. like you said, most likely the patient wasn't able to describe what they were visualizing. many times someone will tell me it's the right eye when it's really the left.

I think we've all said "no, your other right" 10,000 times.

 

[Andrew_Doan]

I think all new patients should be dilated. There could be problems like a choroidal melanoma, diabetes, hypertensive retinopathy, glaucoma, or other problems that can be detected only with a complete dilated, ophthalmological examination. It is not low yield if you're diagnosing diabetes or hypertension. This can save someone's life. See these cases:

http://www.eyerounds.org/case17.htm

and

http://www.eyerounds.org/case1.htm

Also, to automatically dilate everyone is also dangerous if you're not checking for a RAPD first. Some serious problems will be overlooked if the doctor does not know about a RAPD.

If optometry wants to gain respect as being primary care providers for eyes, then you all need to take this responsibility seriously. I routinely dilate ALL new patients.

 

[JennyW]

cpw-it was superior detachment. I did not do a visual field to confirm an inferior defect, counting fingers revealed no defect, and that isn't the point. Either this pt was unable to accurately articulate the symptom, or their were'nt any symptoms related to a retinal detachment. I did a ROUTINE dilation, as the pt was new to the office. Needless to say there was nothing wrong with the eyelid.

Oh, and the person I was trying to discuss had about 20 percent of their retina detached, superiorly (ie, droopy lid). For the record, standards of care are general guidelines and represent the minimum requirement. It's my opinion that going above these standards is not only commonplace, but our responsibility.

In the above statement, you imply that the symptoms that the patient reported of a "droopy eyelid" (which you contend was not droopy on examination) were the result of his superior detachment.

I'm still hoping that you will share at least some of what these numerous sight and life threatening conditions you are finding or claim to have found on routine dilation of patients who normally wouldn't have risk factors for retinal disease.

Your point is well taken about going "above the standard of care" but does that mean that we should start sending asymptomatic 25 year old women for mammograms because there is a chance (however small) that they might have breast cancer? That would certainly be "going above the standard of care." How about colonoscopies for everyone starting at age 21?

Jenny

 

[JennyW]

I think all new patients should be dilated. There could be problems like a choroidal melanoma, diabetes, hypertensive retinopathy, glaucoma, or other problems that can be detected only with a complete dilated, ophthalmological examination.

Also, to automatically dilate everyone is also dangerous if you're not checking for a RAPD. Some serious problems will be overlooked if the doctor does not know about a RAPD.

If optometry wants to gain respect as being primary care providers for eyes, then you all need to take this responsibility seriously. I routinely dilate ALL new patients.

That's a legitimate point and I also dilate all new patients. But PBEA made a contention that a doctor is culpable of malpractice in all cases where a dilated exam was not performed on a patient and pathology was missed. I content that there are cases where that would not be true.

In the cases that posted the links to, both those patients were EXTREMELY symptomatic and it's obvious to all that dilation would be waranted in those cases. Even if one was foolish enough to NOT think dilation was waranted, you would be able to find those lesions with a direct ophthalmoscope and THAT should lead you to dilate the patient.

Jenny

 

[Andrew_Doan]

Your point is well taken about going "above the standard of care" but does that mean that we should start sending asymptomatic 25 year old women for mammograms because there is a chance (however small) that they might have breast cancer? That would certainly be "going above the standard of care." How about colonoscopies for everyone starting at age 21?

Jenny

Jenny,

Dilated examinations are NOT similar to a diagnostic test like a mammogram. A dilated examination is part of the physical examination for the eye, similar to listening to the heart and lungs for an internist. Can you imagine an internist skipping the heart and lung examination to miss AFIB???

Dilated examinations can pick up many common systemic eye diseases in 'routine' populations.

 

[JennyW]

Jenny,

Dilated examinations are NOT similar to a diagnostic test like a mammogram. A dilated examination is part of the physical examination for the eye, similar to listening to the heart and lungs for an internist. Can you imagine an internist skipping the heart and lung examination to miss AFIB???

Dilated examinations can pick up many common systemic eye diseases in 'routine' populations.

A colonoscopy is part of the physical examination of the colon. I'm not sure I completely understand the argument there.

But I agree with you about picking up common systemic diseases. But I am saying that there are patients where dilation is not waranted and missing a pathology in these patients would not automatically make someone culpable of malpractice.

Jenny

 

[Andrew_Doan]

A colonoscopy is part of the physical examination of the colon. I'm not sure I completely understand the argument there.

But I agree with you about picking up common systemic diseases. But I am saying that there are patients where dilation is not waranted and missing a pathology in these patients would not automatically make someone culpable of malpractice.

Jenny

A colonoscopy is recommend for all people after age 50 UNLESS there is a problem.

Is there an age when dilated exams are recommended?

I'm just saying that dilated exams should be done on all new patients that have never had dilated exams before. This is good medical practice and good service to patients; however, I'm not arguing about malpractice here.

 

[cpw]

Also, to automatically dilate everyone is also dangerous if you're not checking for a RAPD first. Some serious problems will be overlooked if the doctor does not know about a RAPD.

If optometry wants to gain respect as being primary care providers for eyes, then you all need to take this responsibility seriously. I routinely dilate ALL new patients.

i dilate all new patients , too. I take acception to you saying I need to take my responsibility seriously. I don't think there's one person here who doesn't take being an optometrist seriously.

All ODs are trained to look for APD. I don't know one that doesn't. (at least that I've worked with) it's part of every preliminary work-up I've ever been through.

Like one of the above posters said, I'm told at least a few times a week that that was, "the most thorough eye exam I've ever had". I take pride in that.

I'm not saying there aren't old school school docs who never dilate, however. But I find that more in the VERY old school ODs out there.

 

[Richard_Hom]

"...If optometry wants to gain respect as being primary care providers for eyes, then you all need to take this responsibility seriously. I routinely dilate ALL new patients.

Dr. Doan,

I think it might cut both ways. Likewise, if an ophthalmologist doesn't dilate every new patient, what would your opinion then be? Again, I've been fortunate to have been on this earth a whole lot of years and have seen a lot of ophthalmologists.

Richard

 

[Andrew_Doan]

Dr. Doan,

I think it might cut both ways. Likewise, if an ophthalmologist doesn't dilate every new patient, what would your opinion then be? Again, I've been fortunate to have been on this earth a whole lot of years and have seen a lot of ophthalmologists.

Richard

I agree. Ophthalmologists need to dilate new patients that haven't been dilated before. We do at the University of Iowa. That's how I am trained, and that's how I will be. I can't speak for my colleagues, but I can only lead by example.

All ODs are trained to look for APD. I don't know one that doesn't.

CPW, I apologize if it seemed that I was implying ODs are NOT trained to look for an APD. I know you are trained to do this. What I meant is that ophthalmologists AND optometrists are too quick to have a tecnician check the RAPD and dilate before the doctor comes into the room to help 'speed' up the examination process. This routine of having a technician dilate may prevent the doctor from detecting a RAPD.

 

[PBEA]

I was just curious. No need to get defensive. It sounds like a great case. like you said, most likely the patient wasn't able to describe what they were visualizing. many times someone will tell me it's the right eye when it's really the left.

I think we've all said "no, your other right" 10,000 times.

I could'nt agree more. I was only trying to emphasize my point, which is that this was a routine DFE. This case is interesting mostly because of the way that the pt presented.

 

[PBEA]

I think all new patients should be dilated. There could be problems like a choroidal melanoma, diabetes, hypertensive retinopathy, glaucoma, or other problems that can be detected only with a complete dilated, ophthalmological examination. It is not low yield if you're diagnosing diabetes or hypertension. This can save someone's life. See these cases:

http://www.eyerounds.org/case17.htm

and

http://www.eyerounds.org/case1.htm

Also, to automatically dilate everyone is also dangerous if you're not checking for a RAPD first. Some serious problems will be overlooked if the doctor does not know about a RAPD.

If optometry wants to gain respect as being primary care providers for eyes, then you all need to take this responsibility seriously. I routinely dilate ALL new patients.

 

[PBEA]

But PBEA made a contention that a doctor is culpable of malpractice in all cases where a dilated exam was not performed on a patient and pathology was missed. I content that there are cases where that would not be true.

In the cases that posted the links to, both those patients were EXTREMELY symptomatic and it's obvious to all that dilation would be waranted in those cases. Even if one was foolish enough to NOT think dilation was waranted, you would be able to find those lesions with a direct ophthalmoscope and THAT should lead you to dilate the patient.

Jenny

I said it before, but I will repeat for your sake. When I said 100% would be culpable, I wrote that I was being figurative, I don't think it is truly 100%. Get it?

 

[JennyW]

I said it before, but I will repeat for your sake. When I said 100% would be culpable, I wrote that I was being figurative, I don't think it is truly 100%. Get it?

That's a strange way of being figurative.

In any event, I'm still hoping you'll share some of these sight or life threatening conditions you are finding on routine dilation. Or were you being figurative there as well?

Jenny

 

[PBEA]

That's a legitimate point and I also dilate all new patients. But PBEA made a contention that a doctor is culpable of malpractice in all cases where a dilated exam was not performed on a patient and pathology was missed. I content that there are cases where that would not be true.

In the cases that posted the links to, both those patients were EXTREMELY symptomatic and it's obvious to all that dilation would be waranted in those cases. Even if one was foolish enough to NOT think dilation was waranted, you would be able to find those lesions with a direct ophthalmoscope and THAT should lead you to dilate the patient.

Jenny

You dilate all new patients? Isn't that counter to what you stated earlier about only dilating pt with risk factors? What happened to your "standard of care"? If a 20 wm, new pt, walks into your office, do you dilate this pt? If you do then why did you say all of these things? Why dilate if there are no risk factors? My guess is because, you wanted to provide a thorough exam. You did not want to be like those other practices (that marginilizes DFE as unecessary). Stop hammering this overstated malpractice issue and recognize that this discussion is about patient care.

 

[PBEA]

That's a strange way of being figurative.

In any event, I'm still hoping you'll share some of these sight or life threatening conditions you are finding on routine dilation. Or were you being figurative there as well?

Jenny

You were right before, you are not being sarcastic, you are being outright antagonistic. My turn. Let me ask you a question. If you are in the practice of recommending no dfe for your "healthy" patients, then how can you possibly claim that this pt population has so few retinal problems? Seems like a catch-22 to me. I mean if your not looking for the elusive presentation, then how can you see the that it is elusive, or that it exists? Perhaps this has more to do with how few cases you have seen over your career, Hmmmmmm.

 

[JennyW]

You dilate all new patients? Isn't that counter to what you stated earlier about only dilating pt with risk factors? What happened to your "standard of care"? If a 20 wm, new pt, walks into your office, do you dilate this pt? If you do then why did you say all of these things? Why dilate if there are no risk factors? My guess is because, you wanted to provide a thorough exam. You did not want to be like those other practices (that marginilizes DFE as unecessary). Stop hammering this overstated malpractice issue and recognize that this discussion is about patient care.

Never once did I say or imply that I do not dilate new patients to my office. Feel free to go back and reread any of my posts. I was making the point that there are certain patients within certain age groups for which a dilated exam is not needed on every visit and that if something were to be missed at one of these visits, the doctor is not always culpable of malpractice which is what you claimed, though you seemed to later recant that by saying you were speaking "figuratively." That's it.

So yes, I would dilate a 20 yo wm if he was new. But if he was a -1.00 and had no other risk factors for retinal disease I wouldn't dilate him again if I saw him the next year or even the year after that.

I would not expect to find anything though. I've probably done about 35000 dilated retinal exams in my career and I can count on one hand the number of sight or life threatening conditions I have found on young healthy asymptomatic patients. You made the implication you were seeing many of these cases and had seen 3 in a 6 month span while working at a Walmart alone.

I've asked you to post some of these cases and you haven't. I still don't understand why. They would be beneficial to the students in this forum.

Jenny

 

[JennyW]

You were right before, you are not being sarcastic, you are being outright antagonistic. My turn. Let me ask you a question. If you are in the practice of recommending no dfe for your "healthy" patients, then how can you possibly claim that this pt population has so few retinal problems? Seems like a catch-22 to me. I mean if your not looking for the elusive presentation, then how can you see the that it is elusive, or that it exists? Perhaps this has more to do with how few cases you have seen over your career, Hmmmmmm.

*sigh*

I never said I do not recommend dilated exams for healthy patients. I said I don't recommend them at EVERY exam. As I said in another post, I've done at LEAST 35000 dilated exams in my career. The number of sight or life threatening conditions that I have found on young asymptomatic patients who would not otherwise have risk factors for disease is less than 5. You claim that you saw 3 in a 6 month time at Walmart.

 

[Bob_Barker27]

PBEA,

I would like to see you post the sight and life threatening cases that Jenny has asked you to provide numerous times now. That doesn't seem like a difficult thing to do if it was a factual claim you made. She's not being antagonistic by simply being skeptical of your claim based on her own experience in the optometry profession, and it appears she has more years of experience in the profession than you do. People are not required to automatically believe everything you claim, and if you can't back up your claims with details, you cannot fault Jenny or the rest of us for remaining skeptical.

 

[cpw]

CPW, I apologize if it seemed that I was implying ODs are NOT trained to look for an APD. I know you are trained to do this. What I meant is that ophthalmologists AND optometrists are too quick to have a tecnician check the RAPD and dilate before the doctor comes into the room to help 'speed' up the examination process. This routine of having a technician dilate may prevent the doctor from detecting a RAPD.

The ophthalmology office where I worked did this while I was on rotations. Although, his technicians were VERY good. If they saw something they grabbed myself and the OMD to come double check before they dropped. But, I was always curious if there were some faint ones they missed because of it. Things the OMD and myself would have caught.

I don't know very many ODs that have techs do prelims and dilate. Most ODs I've worked with , or for , do the pre-lims themselves. Once finished, they'll have the techs just put drops in while they go see their next patient.

 

[Richard_Hom]

The ophthalmology office where I worked did this while I was on rotations. Although, his technicians were VERY good. If they saw something they grabbed myself and the OMD to come double check before they dropped. But, I was always curious if there were some faint ones they missed because of it. Things the OMD and myself would have caught.

I don't know very many ODs that have techs do prelims and dilate. Most ODs I've worked with , or for , do the pre-lims themselves. Once finished, they'll have the techs just put drops in while they go see their next patient.

Dear CPW,

I'm a busy hospital clinic and have trained my MA, OMT's to do this. I'm scheduled for up to 32 / day and sometimes see all of them. They all have to be seen within 6 hours.

Richard

 

[PBEA]

They would be beneficial to the students in this forum.

Jenny

I agree, for the students sake. Only problem is my walmart files are stuck in a box somewhere, and I can't remember every single detail. One was a 20 something woman who had only ever been seen at walmart, routine dfe revealed suspicious looking nevus, turns out melanoma. One was young black kid, routine dfe, large flame shaped heme, turns out systolic was around 180. A few months after he recieved tx, this kid actually stalked me around the general shopping area of walmart. He had wanted to thank me for saving his life, because that is what his physician told him to do, to thank little old me. Imagine that. As for my current office, I refuse to look up the charts, but one was a local high school teacher, routine dfe (which he declined at first), also a retinal detachment. I have a few diabetics who were previously undiagnosed, but retinopathy was present, thank heavens I did a ROUTINE dfe. I had a guy who on routine dfe revealed, venous tortuosity unlike anything I have ever seen, and to top it off, I swear you could literally see that his veins were half full!!! This guy was 20/20 ou. Anyway, the take home message any student should hear from this is that dilation is a requirement for complete examination, if you do not dilate you are not doing a complete exam. Furthermore that you must rely on objective means, and evidence, to demonstrate that the eye is healthy, NOT on statistics or someone else's opinion.

 

[PBEA]

PBEA,

I would like to see you post the sight and life threatening cases that Jenny has asked you to provide numerous times now. That doesn't seem like a difficult thing to do if it was a factual claim you made. She's not being antagonistic by simply being skeptical of your claim based on her own experience in the optometry profession, and it appears she has more years of experience in the profession than you do. People are not required to automatically believe everything you claim, and if you can't back up your claims with details, you cannot fault Jenny or the rest of us for remaining skeptical.

Bob, I have posted some for your benefit, but the fact that I did what you asked does'nt make our discusion of the overall issue any less skeptical. They are mere anecdotes, just like her claims of not having seen anything like what I describe, are just mere anecdotes. A handful of experiences does not make a difference either way, ultimately we are discussing the merits of performing a COMPLETE exam on an individual. The rest is petty digression.

 

[PBEA]

I think all new patients should be dilated. There could be problems like a choroidal melanoma, diabetes, hypertensive retinopathy, glaucoma, or other problems that can be detected only with a complete dilated, ophthalmological examination. It is not low yield if you're diagnosing diabetes or hypertension. This can save someone's life. See these cases:

Thank you for some parity Dr. Doan, I must admit I find it extremely puzzling that I am debating the obvious prescence of asymptomatic ocular disease (albeit rare), with another optometrist, no less. I wonder if jenny sees checking iop in the same way that she sees DFE? Unbelievable

 

[drjs]

I have not had the chance to read through all of the different responses people have had but I would like to shed some light on the type of optometry that I practice at Walmart. I have been practicing now for about 5 months for about 3 days per week and enjoy it immensely. It is my practice: I set my hours, my fees, and how I want things done. If ANYONE were to come in and tell me how I should or should not be practicing, I would and will leave in a heartbeat. I not only do refractions and fit for CLs, but I also manage and treat glaucoma, as well as other medical conditions. My managers (store and district) have never told me that glasses or CLs numbers are down and that I need to push for more exams or Rxs. I said up front to management (of my own will, not because they even mentioned it)that if I feel people do not need glasses, I will not write them an Rx. That is the bottom line. You are the doctor and things should and WILL be run the way you want it run. You have the upper hand especially in stores that have been looking for a Dr for a while. Always remember that. My prices are not the lowest in town in fact I think they are probably among the highest if not right in the middle.
Other perks of working for Walmart: they pay for nearly everything from HCFA forms to submit my insurances to alcohol wipes. The only things I pay for are drops. The priceless thing about working there is having a great staff working for me. They set up my appts, collect monies, and submit some insurances for me. They also do random tasks for me as time allows (remember they are busy running the optical shop as well). It is a strong possibility that I may work there for years to come as long as it continues to grow. EVERY DOCTOR, if they are aim to remain current, RENTS AT LEAST SOME OF THEIR EQUIPMENT. And if they own it all outright, then let's face it: they are not staying up to date with the latest trends because it would take quite a while to pay many of these things off. By the time it is paid off, it is time to update again. I pay 100 dollars a week for all the things I mentioned above, so tell me, how is it exactly that corporate optometry is dictacting how I am to run my practice? Answer: THEY DON'T.
To all those who will be graduating this year, my words of advice: Nothing in life is black and white, so explore many different modes of practice and go with the one that works for you. Possible downsides to working in a corporate setting: the hours you post are the hours they expect you to be there. Don't think you can leave for the day if you only have 3 patients scheduled: that won't fly. To all OD students: Good luck and don't believe everything you hear or read...in the end you need to find out for yourself

I just see a lot of negative posts in here about Wal-mart. You would think Wal-mart was Hitler or something. Wal-mart provides a lot of jobs, and they offer low prices which obviously benefit the poor and middle class. I have heard Wal-mart pays optometrists a competitive salary. I guess I don't see the difference between working as an optometrist in a corporate setting or a private practice, don't you perform the same role in both settings? It seems like having an optometry office in wal-mart makes it convenient for the customer, and don't customers come first in a service profession? I have seen some posts that state that because eye exams are cheaper at Wal-Mart, and that means the quality of care isnt' as good. Does this mean optometrists who work at Wal-mart are slackers? I just don't understand the anti-walmart and anti-big business mindset many young people have.

 

[samwY]

I think its "degrading" only because Walmart is associated with cheap prices, wholesale stocks, and just a trashy image (ie. saturating their buildings everywhere, mostly in lower-middle class communities, etc.).

I'm not saying Walmart isn't good.

 

[Bob_Barker27]

I have not had the chance to read through all of the different responses people have had but I would like to shed some light on the type of optometry that I practice at Walmart. I have been practicing now for about 5 months for about 3 days per week and enjoy it immensely. It is my practice: I set my hours, my fees, and how I want things done. If ANYONE were to come in and tell me how I should or should not be practicing, I would and will leave in a heartbeat. I not only do refractions and fit for CLs, but I also manage and treat glaucoma, as well as other medical conditions. My managers (store and district) have never told me that glasses or CLs numbers are down and that I need to push for more exams or Rxs. I said up front to management (of my own will, not because they even mentioned it)that if I feel people do not need glasses, I will not write them an Rx. That is the bottom line. You are the doctor and things should and WILL be run the way you want it run. You have the upper hand especially in stores that have been looking for a Dr for a while. Always remember that. My prices are not the lowest in town in fact I think they are probably among the highest if not right in the middle.
Other perks of working for Walmart: they pay for nearly everything from HCFA forms to submit my insurances to alcohol wipes. The only things I pay for are drops. The priceless thing about working there is having a great staff working for me. They set up my appts, collect monies, and submit some insurances for me. They also do random tasks for me as time allows (remember they are busy running the optical shop as well). It is a strong possibility that I may work there for years to come as long as it continues to grow. EVERY DOCTOR, if they are aim to remain current, RENTS AT LEAST SOME OF THEIR EQUIPMENT. And if they own it all outright, then let's face it: they are not staying up to date with the latest trends because it would take quite a while to pay many of these things off. By the time it is paid off, it is time to update again. I pay 100 dollars a week for all the things I mentioned above, so tell me, how is it exactly that corporate optometry is dictacting how I am to run my practice? Answer: THEY DON'T.
To all those who will be graduating this year, my words of advice: Nothing in life is black and white, so explore many different modes of practice and go with the one that works for you. Possible downsides to working in a corporate setting: the hours you post are the hours they expect you to be there. Don't think you can leave for the day if you only have 3 patients scheduled: that won't fly. To all OD students: Good luck and don't believe everything you hear or read...in the end you need to find out for yourself

drjs, I appreciate your insider's perspective about working at walmart as an optometrist. I was always skeptical of the claim that Wal-mart is this evil corporation that doesn't let optometrists practice as they see fit. I am having this adrenaline rush right now from the awesome feeling of being right. Tom, who's your daddy?

 

[wrx04]

This is just one of many posts that I read that sounded pretty convincing about Wal-Mart. Check out www.optometry.com for other similar posts.



Posted: Sat Sep 25, 2004 1:55 am Post subject: walmart dr's or potential dr's

--------------------------------------------------------------------------------

Consider this message a very small way of fighting the behemoth that is WalMart. I worked for WalMart as an independent contractor for 2 years, despite having dreams of my own private practice. At the beginning it sounded like the perfect job for any OD with overwhelming student loans. The District Manager brought me in and sat me down, looked me in the eyes and said, " I want you to treat this place like your own private practice. Grow it like it was your own." So I dove in head first, fell in love my office staff and patients, and ONE YEAR LATER the bomb dropped.
This same district manager came into my office and announced that the rent was now 20% of my total gross earnings, despite having told me the year before that it was 10% and would never increase.
She also told me in the same breath that my exam prices were too high and that I should consider lowering them to remain competitive. (She said there were complaints about my prices and I should lower them- these "alleged" complaints were never substantiated)
She also said I was the highest price in town for an eye exam.( TOTAL LIE- in fact I was the second lowest price in town for an eye exam)
She mentioned that the paid yellow pages advertising for WalMart Vision Center was now financially the doctor's responsibility, but not to worry, because it was only about $150/ month. (The statement from the advertising actually came in for about $425/ month)
She topped it all off with " that's the renewal offer, and if you don't like it, we'll understand".
So let me get this straight, I need to LOWER my exam fees to make you happy, AND you're going to take DOUBLE the rent from me that you took before?! Wow. What a great deal...
Fear does funny things to people. My fear of unemployment made me sign the contract for another year. During THIS year, my location went through repeated staff changes and the implementation of HIPAA. Needless to say, the office flow was horrible. Incompetency was abound. Now, contract renewal #2 was up, but this time it was a different story.
The new D.M., we'll call him Mr. Corrupt Representative, told me that WalMart was not renewing my contract. He did not so much as offer a reason, instead said, "WalMart does reserve the right to terminate or not renew contracts without having to give a reason". Professional, huh?
I don't know about all of you other O.D.'s out there, but my aspiration after EIGHT YEARS in school was to get the boot from a guy who probably has no college education, PERIOD.
So, the purpose of my tirade, you ask? Here it is. WalMart is corrupt and engages in price-fixing. They harrass and intimidate. When they come into your office with the contract, they have you write in the hours 10 to 7 and then tell you that you can work whatever hours you see fit. "We just need to show corporate 10 to 7 on paper, what they don't know won't hurt them". No, it won't hurt them, it'll hurt YOU. Because the minute you wise up to the fact that they are politely telling you to lower your prices, you'll realize that what they are doing is illegal. At least in my state it is. If you actually work the hours you "see fit" and don't lower your prices, well, they can fire you for breach of contract because you worked 10 to 6:30 instead of 10 to 7.
Bottom line is this: They think we are stupid and they can walk all over us. I called 37 different Wal-Marts in different states and guess what? The doctor's prices for eye exams are so close (regardless of geographic area) that you HAVE to smell a rat.
Doctors are signing managed care agreements as a PART of the contract renewals! Who is WalMart to tell an independent O.D. what insurance company you're going to participate with?!
If you are thinking of working for WalMart, DON'T. They will squeeze every last ounce of hard work out of you, and then ask you for your soul.
In the process of looking for another job, I have spoken with TWELVE, yes that's TWELVE other O.D.'s that have had THE SAME EXACT EXPERIENCE WITH WALMART. Colleagues, this is not a coincidence, it's a conspiracy.
This D.M. came in to talk to me once when he was doing a store visit, and told me that at his latest district managers meeting in Arkansas there was a poll taken showing how private practices nationwide were going under because of overhead costs, and how WalMart was the wave of the future of optometry. He also offered this stupid "fact" (and I swear he said this, you cannot possibly make up something this stupid) "More people shop at WalMart than read the Sunday paper". Is that supposed to make me feel better about you guys MESSING with me financially?!!
Tell you what, if you actually believe that line of Sugar Honey Iced Tea, especially the bit about private practice being the least lucrative option for an O.D., I have ocean front property in Idaho to sell you...
If you have had a similar experience with WalMart in your town, please get in touch with me. There's a lady at the AOA's legal department who I have been advised to get in touch with.
If you work at WalMart now and just "love it" , don't worry... you'll soon wake up from your daydream, I can almost guarantee it.
My state board already has an investigation in place and they, of course, cannot offer details, but would love concrete evidence such as documents or recorded conversations to help prosecute the appropriate people.
If you don't work at WalMart, you should'nt EVER. would you go to K-Mart to see a podiatrist? I am not undermining O.D.'s that work there because I know they work hard, just like I did. But you have to admit, you shouldn't be able to get an oil change, pick up baby diapers, grocery shop and get your eyes examined under the same roof. WalMart has no business in OUR business. You don't see me trying to sell tires, do you?
Economically speaking, WalMart is the cancer of corporate America. Job out sourcing, hiring illegal aliens for $2 a day, not paying overtime, predatory pricing, the list goes on...
If you want the full picture, pick up a book by Jim Hightower title "Thieves in High Places". Trust me, it is the most eye opening piece of literature I've read to date about WalMart.
If you are currently working at WalMart and afraid to come foward because of their possible "retaliation" aka termination of employment, I recommend you contact your state board and the AOA... and me. Did you all know it only takes THREE people to file a class action lawsuit?

 

[Bob_Barker27]

Economically speaking, WalMart is the cancer of corporate America. Job out sourcing, hiring illegal aliens for $2 a day, not paying overtime, predatory pricing, the list goes on...
If you want the full picture, pick up a book by Jim Hightower title "Thieves in High Places". Trust me, it is the most eye opening piece of literature I've read to date about WalMart.


This sounds like typical anti-walmart propaganda including very hostile and over the top accusations like Walmart is "the cancer of corporate AMerica" and "predatory pricing". It even a sales pitch for a anti-walmart creed entiled Thieves in High Places. I have a hard time trusting anybody that is this emotional about a retail store. THis guy brings up stuff that doesn't even apply to optometrists who work at walmart such as hiring illegal aliens.

 

[rpames]

Bob,

I understand you need to want to think that there are not huge evil people/corp. out there, but there are, and Wal-mart is the mascot.

I would also like to thank drjs for the post, but I would also like to point out something. Drjs has worked there less han 6 mo. He is the ONLY person I have heared that works there and actually thinks it is a good place to be, I would like to speak to him in a year or two. Anyone can enjoy a job that pays a lot for 6mo., but it will start to get to him by the end of the year.

Disclaimer: This not a post say drjs is wrong or misleading us, I'm just saying it is interesting that he is the only Dr. out of several (all of whom worked there) that I have spoken to, that says Wal-mart is worth working for.

rpames

 

[Bob_Barker27]

Bob,

I understand you need to want to think that there are not huge evil people/corp. out there, but there are, and Wal-mart is the mascot.

I would also like to thank drjs for the post, but I would also like to point out something. Drjs has worked there less han 6 mo. He is the ONLY person I have heared that works there and actually thinks it is a good place to be, I would like to speak to him in a year or two. Anyone can enjoy a job that pays a lot for 6mo., but it will start to get to him by the end of the year.

Disclaimer: This not a post say drjs is wrong or misleading us, I'm just saying it is interesting that he is the only Dr. out of several (all of whom worked there) that I have spoken to, that says Wal-mart is worth working for.

rpames

I have seen a few other posts by optometrists that worked at Walmart who said they could practice as they saw fit. An optometrist that does not like working at Walmart does not prove that Walmart is evil. I think the crux of the matter is that many optometrists appear to have left wing politics, and that usually includes an irrational hate of large corporations. As a result, working at Walmart presents an internal conflict for them. They are also often insecure about people viewing them has having less prestige because they work at Walmart, which I think is just the result of personal vanity. The anti-walmart rant in the previous post cites outsourcing as an example of Walmart being EVILLLLLLLLLLLLLLLL. But outsourcing isn't a criminal activity, and if Walmart opens up a retail store in Brazil, obviously they are going to have to hire Brazilians to work there. This would be like me accusing an optometrist of being unethical if he decided to open up a practice in Africa somewhere and he hired some Africans to work in his office. I don't see how anybody can take the writer of the previous post seriously when he is criminalizing everything walmart does even if it's not a crime or unethical.

 

[rpames]

I'm actually a member of the Republican party and very proud of that, but I still find Wal-mart to be bad for the world.

I'm not going to get into a battle about this because neither of us will change our minds by what the other has to say. I'll just say that all the articles and reports I've read and heard about Wal-mart's business practices make me very uncomfortable. One of my minors was in philosophy so I examine every aspect of an issue before I make a firm decision about whether something in unethical. Many of Wal-mart's practices seem to fit my criteria. For that reason I would never work for them as a doctor, even if I could practice anyway I wanted.

 

[Sanman]

well this maybe gettin a little off topic, but here's my question. How, as republican, could a person be for Wal-mart and outsourcing (as many are)? The reason I ask this is because according to republicans, they are for small businesses (at least they were when they opposed the minimum wage hike). Yet, Wal-mart drives the the mom and pop stores and even smaller chains out of business.

 

[Bob_Barker27]

I'm actually a member of the Republican party and very proud of that, but I still find Wal-mart to be bad for the world.

I'm not going to get into a battle about this because neither of us will change our minds by what the other has to say. I'll just say that all the articles and reports I've read and heard about Wal-mart's business practices make me very uncomfortable. One of my minors was in philosophy so I examine every aspect of an issue before I make a firm decision about whether something in unethical. Many of Wal-mart's practices seem to fit my criteria. For that reason I would never work for them as a doctor, even if I could practice anyway I wanted.

I don't think you really understand how business works, which is typical of many in the healthcare profession, it seems. I don't see you stating specifically in your own words what makes Wal-mart unethical. As a result, it makes it difficult for me to refute what you believe. The fact you so quickly dismiss what the optometrist who worked at Walmart had to say seems to indicate you aren't really looking at all sides.

 

[Bob_Barker27]

well this maybe gettin a little off topic, but here's my question. How, as republican, could a person be for Wal-mart and outsourcing (as many are)? The reason I ask this is because according to republicans, they are for small businesses (at least they were when they opposed the minimum wage hike). Yet, Wal-mart drives the the mom and pop stores and even smaller chains out of business.

Republicans are for all businesses, large and small. We support much lower taxation levels for small business than do Democrats. THat's why a majority of small business owners vote for Republicans. The fact that Walmart drives mom and pop stores out of business is not the fault of Republicans, it's the fault of consumers. Consumers choose Walmart with with their wallets, something liberals have a hard time accepting. Again, outscouring is not a criminal or unethical business practice. Many companies from overseas outsource jobs to America, including Honda, Toyota, Fuji Film, BMW. Are you against foreign companies providing jobs in AMerican workers?

 

[rpames]

I don't think you really understand how business works, which is typical of many in the healthcare profession, it seems. I don't see you stating specifically in your own words what makes Wal-mart unethical. As a result, it makes it difficult for me to refute what you believe. The fact you so quickly dismiss what the optometrist who worked at Walmart had to say seems to indicate you aren't really looking at all sides.

Nothing in my post could lead you to any conclusion of my business understanding, so your first statement makes no sense. Second, you are correct that I did not post any specifics about my beliefs toward Wal-mart. That absence is there because of the second sentence in my previous post.

As far as my "quick" judgment of drjs's post? I made no judgment, I only stated my observations. At no point did I say he was wrong, I just (in not so may words) said it was interesting that his view of working at Wal-mart was an anomaly in all the stories that I have heard.

At this point I will stop posting on this thread b/c there seems to be no progress here, nor is it forseeable.

 

[Bob_Barker27]

Nothing in my post could lead you to any conclusion of my business understanding, so your first statement makes no sense. Second, you are correct that I did not post any specifics about my beliefs toward Wal-mart. That absence is there because of the second sentence in my previous post.

As far as my "quick" judgment of drjs's post? I made no judgment, I only stated my observations. At no point did I say he was wrong, I just (in not so may words) said it was interesting that his view of working at Wal-mart was an anomaly in all the stories that I have heard.

At this point I will stop posting on this thread b/c there seems to be no progress here, nor is it forseeable.

You were predicting he would hate working at walmart soon. That is a judgement, a rather negative and pessimistic one. It's almost like you are HOPING this will come to pass. When you accuse Walmart of being unethical, but don't provide specifics, I think it is reasonable to conclude you really cannot discuss the issue intelligently. All I have seen you do on this subject is point to articles you have read, agree with others in here who are anti-Walmart, and submit your philosophy minor as evidence that you know what you are talking about. I don't understand why you take the time to respond to me if you aren't going to attempt to provide any specific proof that walmart is evil. Nobody has to just take your word for it.