I’ve been on rotation at the Memphis VA for the last four months, and one of our “assignments” is to do a case presentation and a general presentation about optometry. After my epiphany the other day, I decided that my general presentation should take on a “we’re about to graduate” tone, as all of the people I was presenting to are fourth years (and my staff ODs). For those of you who fit the bill, I thought I’d share pieces of my presentation with you as well…

WHAT TO DO IN THE NEXT SIX MONTHS:
1) Residencies: If you are planning on applying, get on it! Applications are due on February 1, 2012. You can find out more information about residency programs and applications at the Optometric Residency Matching Service, Inc.

2)Looking for a Job: Get your resume ready and start looking. There are several job search sites out there, not to mention the wealth of information offered at your schools and state associations.

3)Loans (what a drag…): Find out how much you really owe by checking with the National Student Loan Data System (NSLDS) and check your credit report for private loans from undergrad. If you want to find out what your loan payments will be or if you should consolidate, look at the Direct Loan Consolidation site through the US Dept of Ed.

4) Get a License: First things first…make sure you’ve graduated and passed all parts of NBEO boards before applying. Then, check with your local state board to find out what you need to do to apply for a license. Every state is different! Do you need multiple licenses? Check with ARBO (Association of Regulatory Boards of Optometry) to see if your state is a part of the licensure mobility program (CELMO) – which allows you to use one state license in different states.

6) There’s More? YES! Join the AOA and your state affiliate to keep up-to-date and involved in organized optometry. Our profession can’t exist without your support and membership in it!

7)Be an optometric philanthropist…sort of… Have you thought about doing InfantSEE or VISION USA exams? You’ll need to sign up with each program to become one of their providers. It’s really easy, and you get to help your community in a BIG, BIG way! Think about it!

8 ) NPI Numbers. This one’s easy. The national provider identification number is provided by the National Plan and Provider Enumeration System (NPPES) and is required by HIPPAA. It takes 20 minutes online to get one.

9) DEA number. This one’s important too! Know what schedules your state can prescribe. You’ll have to submit a national application and a state application for every state in which you are licensed/working. These numbers are renewed every three years.

10)Get malpractice insurance. This is sooo inexpensive for our profession. I got my “quick quote” from the AOA Endorsed Malpractice Insurance Company the other day…only $347 for the year (which includes my 25% new graduate discount)!

11) You may already know your OE Tracker number, but it’s not just important for boards. This number will track all of your CE electronically for you. If you need a list, you pay a $20 fee for a year’s worth of access to your recorded CE. Even if you don’t pay, it’s still recorded…gotta love that!

Holy moly! Did that overwhelm you as much as it did me? If so, or if you don’t want to have to google everything in my list, check out AOA Compass. It’s a personalized checklist (with links to everything and more!) regarding all of the topics that I’ve discussed, plus more. If you aren’t a fourth year, but want to get started early go for it! The checklist starts with Day one of optometry school and goes through your first steps as a new graduate. It’s really a great tool. You’ll need your AOA/AOSA Member number to log-on (your trustee has it if you need it). Here’s the link: http://sso.aoa.org/logincompass.aspx

Good luck to everyone taking finals. To my fellow fourth years who will be graduating soon, hopefully this post will help ease your life transitions a little! Happy holidays!
-Elizabeth

I know it has been a little while since I blogged but life is busy and that is a good thing. I am currently half way through my military commitment. So far, I have learned so much about real life optometry. I have come to the realization that you can not please every person. I think it is important to put all the effort into pleasing patients and devoting your practice for customer service. But some patients can’t be pleased and that’s real life. The important thing to remember is to not take it personally. I have only had a couple of patients that have been displeased and I took it real personally but after evaluating our practice and the process’s I realized it was the patient. But always try to keep a fresh mind on how you do things. Always evaluate your process and staff and that evaluations will make your life interesting. I want to thank AOSA for the opportunity to blog and please feel free to contact me at anytime at tyson_allard@yahoo.com

Thanks,

Dr. Tyson Allard

USAF

This post is for anyone who still refracts like they taught you in refraction 101 (and not how real practicing OD’s do it). The key is to save time but still be accurate. Another key is to give the patient easy choices. Patients are afraid they are giving the wrong answers and it can be stressful for them, if you always remember their point of view it will make the refraction go smoother.

When checking initial VA’s. I like to isolate a vertical line of letters to figure out where they are approximately. That way they aren’t allow to read the entire chart top-to-bottom that some patients like to do when given the chance but also gives them the ability to show me their acuity from 20/40 to 20/20 for instance without having to scroll around to show them a lot of different lines. From there you can continue to check different lines yourself but this is a good start.

Starting: Best way is dialing in the habitual Rx into the phoropter. If you can’t, start with auto-refraction or retinoscopy. Never start from zero if you can help it.

Options: Make sure to educate them that saying “no difference” or “same” or “I can’t tell” is a fine response, some patients won’t realize this and you won’t realize they don’t know this until you are spinning round and round on JCC because they think one of the choices is the right choice between 1 and 2 when there is no difference.

Fog: Unless I am suspicious they are incredibly over-minused, I don’t fog more than 2-3 clicks. I then go BVA from there. Also, I like to start refracting with a line they can read easily. I don’t refract showing the complete chart but just isolate horizontal lines of 20/40 or 20/20 most of the time. As a patient, it is more stressful to see letters you can’t read further down the chart.

JCC: This goes back to giving patient easy choices. For axis refinement, if their axis is 180, I don’t start my JCC at 180 because it forces them to differentiate between choices which may be very similar (hence “not easy” choices). This can be frustrating for them and you when they bounce all over the place. I start at around 170 and then check if they lead me back to 180 (an easy choice if they truly like their habitual of 180), if they do I move to 10 and see if they move me back to 180. If so, I am done with axis refinement.

For someone who I am checking if they have cyl at all, I start with -0.50 cyl and see if they reject it at 180,90, 135, 45.

Talk slowly but move quickly. If you speak calmly they won’t feel rushed – because if they feel rushed they won’t feel like they are getting the right Rx. Be very complimentary as in “you are doing great.” Having two hands on the phoropter dials can save a little time with JCC.

Bonus round! When I think a patient will read 20/20 or even 20/25 but don’t want them to stress if they can’t do it. I like to say “okay, bonus points if you can read these letters, they are VERY small.” If they can get my bonus points which is the 20/20 line, I say “wow, great work, those were real small!”If they read 20/20, I like to say “you just read 20/20, and as you know that’s basically the limits of human vision!”

This is also good for the picky patient who can read 20/20 or even 20/15 but always has to throw in “but it wasn’t that clear” (who also has cataracts by the way). Hey, it wasn’t clear but it was the bonus round anyway I remind them! =)

Patients are scared when their vision is poor, but love it when they are exceeding expectations. The trick is you can artificially set low expectations to give yourself the opportunity to compliment them when they have surpassed your made-up goals (patients love getting extra letters on the bonus round).

Binocular BVA – I don’t want to see the patient for an Rx recheck and over-plussing a patient (besides cyl changes) is one of the most common things students/new OD’s are guilty of. When I am at the end-point of my binocular BVA, I then ask them to differentiate by adding +0.25 and say “does this blur you at all?” This is better than asking “1″ or “2″. If he/she says it makes it even a little blurry, I am done.

20/15?! I don’t show them this line often at VA Vegas. When I do it is always near the end. This goes back to my desire to avoid showing lines that patients won’t be able to see to avoid their frustration.

* addendum: because a dozen people have asked me recently, these are my just tips and not my complete refraction process (so I do indeed do binocular balance!)

Lastly, this doesn’t have to do with refraction but when working with a 90D lens, if you are still mastering it always start with LOW magnification. It’ll be easier to aim the beam into the pupil and to figure out where you are in the retina if you start with lower mag.

Thanh Mai, proud AOSA member/contributor

Current SCCO student c/o 2012, who also maintains an optometry blog at blog.drmai.info

Working at a Veteran Affairs clinic

Before I entered optometry school, I really didn’t know what to expect.  I knew that there’d be lots of lectures and tests, but what would my clinical education be like?  Would a professor be in the exam room with me?  Or a classmate?  Or–  Would I be alone?

My first patient was a random café owner that had a “white spot” on her eye.  I gave the exam alone, and it was the fastest two-and-a-half hours of my life.

She only had a pterygium, but when I first saw it, I was absolutely terrified.  There’s a big difference between seeing something in a book and having it sit in your chair!  That day, I spent a lot of time asking my staff doctors what to do.  Honestly, I wasn’t very confident at all.

Now, as a fourth year student, things are different.  My current rotation is a Veteran Affairs (VA) clinic in Bakersfield, California.  I am now given much more autonomy to run my exams.  In fact, I almost always give the entire exam before presenting my findings to a staff doctor.  And that’s how it should be, because I’ll be graduating in half a year.

This rotation has been a completely immersive full-time-job-like learning experience.  In a typical day, I arrive at 7:50 am and check my room to make sure everything is ready.  If I have a few minutes, I briefly review the schedule.  At this point, everything should look familiar since I have already reviewed my patients earlier in the week.

I usually have about 10-12 exams with the majority requiring dilation to check the back of their eyes.  At 8:00, I bring in my first patient.  I try to do the case history, entrance testing, refraction, anterior segment evaluation and get dilating drops in their eyes within 20 minutes.  That may sound fast, but you will get used to getting things done quickly–  Especially when you know your next patient is already waiting for you in the lobby.

After my first patient is dilated, I send them to optical to pick their glasses.  Then, I bring in my second patient and repeat the initial exam process.  After my second patient leaves for optical, I bring my first patient back and check the back of the eye.  Sometimes, this only takes 10 minutes, but often I need more time — especially if there’s a lot going on.

When I’ve completed my examination, I present my findings to the staff doctor, who has an exam lane right next door.  I then introduce the first patient to him and make a quick escape to finish my second patient’s examination.

This cycle basically repeats over and over again until the late afternoon.  Finally, after my last patient, I turn on some music, relax, review patients with my staff doctor and work on charts.  With luck, I’ll be out the door by 5:30 and on my way home.

How do I get ready for my rotation?

Try your best to speed up your exams without compromising patient care.  The official time VA estimate for an anterior segment slit lamp evaluation is 1 minute per eye.  Gonioscopy should also only take 1 minute per eye.  This might seem daunting when you’re first learning how to use a slit lamp, but you can do it if you practice.

Also, review common diseases like diabetic retinopathy, macular degeneration, and glaucoma.  You’ll see a lot of that and you’ll want to talk intelligently about them.

Finally, relax and be ready for a great time!  By this point, you’ve already finished the hardest part of optometry school, and you’ll finally be able to have a social life.  It will amaze you to see how much you’ve learned over the past few years, and how much you can help people with the knowledge and skills you already have.

Until next time!

Dave Shin
Class of 2012
Southern California College of Optometry

Today I took part III of boards. All in all it went pretty well, but I must say that I’m glad that we tried to find the building the night before. Tall buildings make it tough to read the signs at the top. There are tons of great restaurants around, and our hotel was awesome. I stayed at the Hampton, which was a little less than a mile from the BB&T building, and there was a shuttle that took us from the hotel to anywhere within a three mile radius. Right now, I’m sitting at a neat little irish pub, drinking a great irish beer in celebration of meeting another milestone in my career. Good luck and no stress to everyone else this year!

WRC stands for Western Regional Conference and it is a student conference hosted by the schools of Optometry on the west coast. It was started by University of California, Berkley as a means to not only meet future colleagues at various schools but also visit other Optometry schools. It widens your perspective on what Optometry is and does. This conference has a history of rotating through the west schools and is put on by the local AOSA representatives or trustees. This coming October 21-22 Marc Kallal (AOSA trustee for Southern California College of Optometry), Brian Park (AOSA trustee-elect for SCCO), and their committees of student volunteers will be hosting this fantastic event.

I can’t put in words just how excited I am. First of all I feel very privileged to get the opportunity to, so soon after my graduation, travel back to my alma mater and address students from across the western United States. I had so many unique experiences through my leadership in school, I am very excited to share some of that passion and excitement for this profession! In addition to the keynote address, I have the opportunity to attend the other great lectures and to re-unite with friends/faculty! If there is one thing I absolutely love about being involved in Optometry, is is that this profession truly is small and feels like a family, every meeting I go to makes me excited to re-connect with friends and mentors from across the country and WRC @ SCCO will be no exception!

Students: If you have not yet attended a conference in which you get to meet colleagues from other areas, I encourage you to look for one in an area near you!

Until next time—Happy exams!

Dr. Saysha

Same as in the States, “money talks.” Like I’ve mentioned before, some patients have to travel very far and can’t afford to wait for a surgery that they have been referred  for; but they can afford for a rushed appointment with the doctor. The doctors that service the VIP clinic have the same equipment and operating rooms as the rest of the hospital, just in a smaller scale. These patients also give up their right to choose a specific surgeon for their ocular healthcare.

Dr. “granny” Wang is one of the main doctors and has been in practice since the 50′s…patients and staff love her! In a typical day, she manages cases of scleritis to trauma to CRVO’s! One of the patients came in for a simple Avastin injection all the way from Beijing (over 800 miles away). It turns out that there are legislative issues facing eye doctors in China as well– this patient had to come to Shanghai for his intravitreal injection because of government rulings that restrict the practice of steroid injections to certain hospitals with the “correct” regulations. This didn’t seem like very accessible “universal healthcare” for the patient, similar to an issue our patients in the States with a pending Medicaid related HR1219 bill.

Unfortunately, within the US Medicaid program, there has been restricted access and few, if any, choices when it comes to essential eye health care for these patients. Medicare patients in some states are restricted to be seen only by subscribing ophthalmology providers; even though optometrists (that’s us, students, in the near future!) have long provided up to 81% — of primary eye health and vision care for Medicaid patients. This discrepancy exists even though we are all trained, licensed and ready to provide. In addition to restricting access to care, the existing law allows bureaucrats and, increasingly, managed care companies to make important medical decisions for patients who need eye care. This type of outdated provider discrimination can result in delayed or even denied care for an eye diseases like glaucoma, a serious infection, a foreign body in the eye, an undiagnosed vision disorder or even diabetes– the leading cause of acquired blindness for adults. In addition, taxpayers ultimately pay even higher costs when much-needed access to primary care is restricted.

So, optometry students out there… be on the lookout on how you and your local AOSA Trustee/elect can influence bills like HR 1219 directly in Washington DC! In the meantime, AOA-PAC is a great association you can join within the AOSA/AOA family that specifically helps the optometry profession have a loud voice on Capitol Hill matters.

Typical OR... there are 12 OR's in the surgical eye ward and most surgeries are before lunchtime. That means that rounds are at 7am every morning for the residents and attendings!

There are multiple camera screens set up around the OR for learning purposes. There can up to 12 residents/attendings in 1 OR depending on how "popular" the surgeon is that is operating!

Retinal detachment vitrectomy...they found the RD after the cataract extraction! And, it was not present on the B-scan done 2 days prior to surgery... you can even see the lil flap of retina waving around in the middle of the viewing lens!

The Glaucoma and Cataract Surgery ward has a very hectic feeling everyday. There are many surgeries scheduled each day — congenital cataracts, lens subluxation, age-related cataracts, diabetic cataracts, trabeculotomies, iridotomies, etc — that start with a work-up the day before and a final pre-op round early in the morning. Patients travel 1,000′s of miles to get treatment at this hospital because of the famous surgeons and the renowned procedures. One interesting case was a 5-yo boy with his lens subluxed laterally in both eyes. With an unremarkable case history (no trauma or diagnosed systemic disease), the doctors probed into his development and onset of his blurry vision. Upon his physical exam, we noticed that he had bouts of labored breathing, long fingers and extremities, and an irregular (heart murmur?) heartbeat. He also had concurrent high myopia (not really that astounding in China) with the onset of blurry vision estimated about 1 year ago. Since his family lives in a remote village, it took him and his father a while to find time to visit the hospital for eye care. He also has a little brother who is “short and chubby” instead of his “tall and skinny” build. Yup, he had Marfan’s Syndrome! Hence, the doctors opted not to  proceed with the lens removal surgery until he had a thorough examination with a pediatric cardiologist at the nearby hospital.

This case really brought home the idea that (even in the States), since you might be the only doctor they see when patients come to you for eye care, to be especially vigilant for concurrent systemic conditions. We are fortunate to be in a field where there are many possible clinical correlations to ocular findings!

When I started optometry school, I thought I had the perfect plan. I knew what was expected of me, what faults I had in studying from college, and how to relate to people…I thought. During orientation we learned that we should study a little each day instead of cramming, not get sick, get good sleep, and make sure to exercise or do the things that we love in life that aren’t school related. So I decided to make some habit changes and be a successful optometry student. The weekend between orientation and the first day of class, I made a study calendar – one or two hours a day in varied subjects to stay on task, plus time to hit the gym and relax.  I also attended my great-grandmother’s 96th birthday party.

Monday arrived and I was up early – a totally new concept for me – and doing a load of laundry. I got to school and followed my plans for the day. I came home and studied, went to my yoga class, and watched a little tv.  I heated up my leftovers from my great-grandmother’s party for dinner. Then, I woke up in the middle of the night with the worst food poisoning ever. It was terrible. Not only was I stressed because I wasn’t getting enough sleep that night or because I was incredibily ill, but I knew that I was going to miss the second day.  I was starting out doing all of the things that I was told were the worst things to do during orientation, and it was only the second day.  I had lost control of the situation and it happened so fast.

As the semester passed, I started to get back on track, but felt like everything was still spiraling out of control. I was depressed and my grades weren’t all that I wanted them to be. That’s when I realized that life isn’t about fitting into a specific mold – something I had always known, but didn’t realize that I was trying to do.  I wasn’t functioning at my best and happiest in the schedule that I had created. I wasn’t allowing myself to escape when I scheduled it in. So I started making changes . . . lots of them.

Chris, the practice management consultant, gave everyone a quiz today. It was one of those personality profile things that are everywhere. Ultimately, the point of his quiz and meeting time was that the office team needed to establish balance.  When he asked everyone how to establish balance, I thought about my experiences during my first year of optometry school. It’s really all about knowing your strengths and weaknesses . . . really knowing them . . . and embracing them.

I learned more about myself during my first year of optometry school, than I have during most of the rest of my life. I came from a depressed, unproductive, unhappy, unhealthy place to where I am today.  I’m planning a wedding, taking boards, seeing patients, doing yoga, and being very active in the world of organized optometry. Some would be very overwhelmed with that list, but it’s filled with things that make me happy. Is it tough? Absolutely! There are days when I’m stressed beyond belief, but I’m thrilled to have the opportunities I’ve got. I found out that being more involved helped me find my balance. When I was doing the things I loved to do, and being with the people that I love to be with, studying took less time and was ten times more productive. School was easier and more enjoyable.

I know this has been long, but I feel like this is probably the story of most optometry students…or at least a good chunk of them. It’s not something that people want to talk about because it makes them feel weak or less capable than their peers. Embrace your weaknesses, it makes you stronger and helps you find your balance…and ultimately makes you happier.

Good luck and have a great year!

Crowd outside the eye clinic...notice how there is no "real" line!

Fudan University Eye and ENT Hospital Wards (mostly surgical wards)

The Contact Lens clinic also has something blatantly different…almost all of the patients are kids  (and there are tons) under 10 years old! Some recent papers and research have dubbed progressive myopia as an “epidemic” in China among it’s younger population. The doctors’ answer is to begin fitting RGP’s and Ortho-K lenses on children as young as 4 years old to slow the progression of myopia. Dr. Le told me that the stress these kids face in the Chinese education system really lends itself to these extraordinary fittings. For example, Shanghai’s public primary school system (non-college level) has been listed as the most strenuous and best system in the whole world the past few years! I scrubbed in 2 days in the operating room observing LASIK, LASEK, Intralase, PRK, and Strabismus retraction surgery.

There were 2 doctors, 2 residents, and 4 techs in the operating room during the laser refractive surgery day. LASEK is more common here due to the stability of the thin flap procedure (helpful in higher myopes since more stroma will be ablated with the excimer laser), despite the longer and more painful healing time. I also noticed that many of the patients opted for Intralase (with a femptosecond laser replacing the microkeratoma blade cut) due to the safety of a computer guided corneal flap system and the likelihood of fewer touch-up treatments that would be needed. Shockingly, these doctors operated on about 100 patients in just 1 day…and it only costs the patients $800 USD per surgery!

Surgical correction for long-standing strabismus was also very efficient with just one doctor, one resident, and 2 techs completing about 25 patients in day! I observed as they computed and implemented very precise EOM measurements depending on each patients’ binocular status. Each strabismus patient (usually younger children) must complete a full Binocular Vision, Ocular Motor, and Visual acuity exam prior to surgery. At that time, it will be deemed whether it would be more favorable to continue vision/prism therapy or surgery. The surgery requires either moving the targeted EOM forward or backward after cutting it free from the insertion point on the globe… it actually wasn’t as bloody as I thought it would be that day! Alrighty…I’m off to the Glaucoma and Cataracts ward next week!

Thanks for reading ~Vicky

My new White Coat! and they even clean them for us every week!