Can't Find Qualified Help?
Then you've got some tech training to do. Use these practical tips to keep it moving smoothly.
By Jane Shuman, C.O.E., C.O.T., M.S.M., Dedham, Mass.

The infrequent opportunity to hire qualified personnel is a problem confronting ophthalmic practices nationwide. Contributing to the problem, as the Los Angeles Times reported in its June 4, 2000 issue, has been the drain on the supply of allied health personnel in ophthalmology by the staffing needs of laser vision correction centers. The situation is particularly frustrating as it comes at a time when practices are striving to increase their productivity.

If you're lucky, certified personnel, who would need only minimal acclimation to your protocols, respond to your classified ad. If you're really lucky, the applicants are self-starters and know what needs to be done without being told. If your luck is running off the charts, they're a good fit with the other personalities in your office, and your team is complete.

Unfortunately, more often than not, that's not the case. Applicants aren't as qualified as they lead you to believe, and they learn more slowly than you had hoped. If your practice is typical, you're forced to take a calculated risk and train your new staff member by yourself. And you'll be investing at least a year's worth of time, effort and money in converting your novice into a productive technician.

How, then, do you know whom to hire? Answer these questions to your satisfaction:

Is the applicant a good communicator? This means listening as well as speaking. She must hear what the patient is saying about his eyes in order to take a comprehensive history. She must be able to initiate conversation, speaking clearly and slowly, as necessary. She must be able to work one-on-one with patients and as part of a team with the staff.

It's easy to determine how well the applicant speaks. To help you assess the other characteristics, which is more difficult, ask the applicant to describe past events that might demonstrate the desired behaviors. For example, how has the candidate dealt with a patient, or customer, who felt entitled to service that wasn't available? Did she convey possible alternatives or just said "no"? If the applicant is coming from another practice, how has she handled medical emergencies?

Is the applicant going to be able to handle the stressors that may come her way? Every practice has clinically, as well as emotionally, difficult patients. Can your job applicant demonstrate how she's handled similar people in her previous jobs? Many service-oriented positions, such as waitresses, retail clerks, and airline personnel, deal with the same consumer demands that ophthalmic technicians see. A customer-service focus will transfer easily to the medical field.

Patients today verbalize their expectations from a physician encounter. They compare notes with their friends and family and will change practices for the perception of increased care and attention. Applicants who can treat the patient as a customer will provide a higher-than-average level of customer service, and do it with natural grace. Those applicants who view each patient as another set of eyes will become the technicians who are merely people-movers.

Is the applicant technically inclined? If she's an auto mechanic, the answer is probably yes. If not, it may be difficult to determine how quickly she'll learn the skills necessary to do her job. Find out what's motivating this candidate to apply for a job in this field.

It may be a familiarity with the discipline because a family member has had eye problems. It might be a fascination with the field lived vicariously through a friend, or it may be curiosity. Any of these will motivate her to learn and achieve.

Or, it may be money. A secretary in the practice may discover that technical personnel earn more per hour than the clerical support. Hiring from within has its benefits, mainly that the employee already understands many of your policies and you've seen her work ethic firsthand. But when a current employee is an applicant, someone should monitor how she speaks to her co-workers and patients in her current position. Does she use first names, when the practice standard is a title and surname? Is she gruff or compassionate? How she behaves in her current position will indicate how she'll treat the patients as a technician.

Does she understand the glasses prescriptions she re-issues? Does she ask questions that indicate her desire to piece together information? If so, she'll probably succeed as a technician. It is, however, more difficult to access her technical potential. There are personality and aptitude tests you can administer to help determine her strengths. But, keep in mind, that if you require one applicant to take such tests, you must require it of every applicant.

Some basics

Whether your new hire is from outside or within, she must first understand that she'll be working under the licensure of the physician. She's to perform all diagnostic tests according to practice standards.

Also, you can't stress compliance enough to the new assistant. She must understand the necessity of documenting everything accurately and legibly. It's a common misconception that compliance pertains only to proper coding.  Therefore, the new staff member should be instructed from the onset that compliance is involved in everything that transpires between her and the patient. You must advise her to document everything, leaving nothing unwritten. Everything she records must be legible to the point that three people, other than physicians, can read the notes. In other words, a person who is unfamiliar with your practice should be able to read a patient's record and know exactly what transpired during a visit.

Confidentiality can't be stressed enough to the new hire either, particularly with the upcoming HIPPA regulations.

Let the training begin

Once the new hire understands the above, it's time to begin her training. What follows is practical advice you can apply to key stages of the training process that will keep it moving as smoothly as possible for the new hire and the entire practice.

Shadowing. As tempted as you may be to have a new hire "jump right in," having her observe your lead technician is time well spent. She'll observe the preferred methods of testing and documentation; she'll discuss protocols for various medical conditions; and she'll note the acceptable level of respect and familiarity paid to the patient. She'll also have an opportunity to discuss how your procedures differ from her previous employer's procedures.

If your new employee comes to you with ophthalmic experience, have her observe for a day or two, and then switch places with your lead technician. The lead tech can suggest efficiencies while observing firsthand the new hire's interactions with your patients.

Once both are comfortable with the situation, the new hire should be allowed to work-up patients on her own. The lead technician, however, should remain available for questions as they occur. More than likely, the new employee will initially be slower in her work-ups than your other technical staff. It helps to provide her with a list of the various visit types and what tests you prefer for each.

The "why" of it all. To be effective, the new hire needs to learn not only the skill, but the rationale behind it. For example, she must be told why it's so important to look for an afferent pupillary defect. What might it indicate, and why should she not dilate that patient's eyes? This process should be applied to each skill that she learns.

Key skills. The first skills a new hire should be taught are those that pertain to case history, review of systems and past, family and social history. To ensure continuing compliance, proper initial instruction is crucial.

Main points, such as ascertaining the reason the patient is in your office (i.e., return visit for an existing condition, or for a new complaint) must be emphasized. The new tech must also understand that her role is to search for as many quantifiers as she can about the ocular condition, and not about the glasses the patient is currently wearing.

At this stage of training, a templated visit note helps tremendously. In fact, with the increasing focus that's placed on compliance, more and more practices are using such visit templates. They foster compliance and serve as a valuable training tool by requiring entries in each category and forcing entry of both positive and negative findings.

Automated equipment. As a next step, automated equipment is an excellent starting point for learning many concepts and skills, including optics and refraction. Once she's reading figures from the automated lensmeter, a new tech will begin to understand how they coincide with figures from the autorefractor and how the refractive error should mesh with the final manifest.

Another useful function for the novice technician is Humphrey visual field testing. Once she's shown how to position the patient and operate the instrument, the employee feels productive, and the practice benefits from having an additional tester.

Added tasks. Once she's comfortable with these tasks, it's time to move on to other tasks, such as pupillary examination, confrontational field testing, Amsler-grid testing and color testing. As previously stated, the new tech should be getting an understanding of the significance of abnormal results, which will later help her understand the disease process. During this period, pair the new tech with another, faster tech to help minimize interruptions in patient flow.

Refraction and intraocular pressure testing. Reserve teaching your new technician refractometry and applanation tension until both of you are comfortable with her progress to date. Of these two skills, introduce IOP measurement first because, once mastered, it requires much less of the technician's time, saving refractions for those staff members who are able to refract more quickly.

Applanation tension is really the first task your new technician will confront that can result in physical harm to your patient if performed incorrectly. It's important to acknowledge the assistant's fear in this regard, while encouraging her to continue to progress.

Once she understands the principle behind this measurement, she'll need to view ghost and actual mires. Some practices own learning tubes so that the student and the established technician can view the mires simultaneously. If you don't own one, the process is a little slower as the technician must pause as the student views the ghost mires and then the actual mires through the slit lamp. If you don't own a teaching eye, a finger of a rubber glove can be painted to resemble an eye, filled with water, twisted and held in front of the tonometer tip. Or, more bravely, a co-worker can pretend to be the patient while the lead technician watches closely, guiding the new hire to center the prism on the cornea.

Once she's accurately measured staff IOP at least half a dozen times, the new tech can move on to a real patient. The best to start with are glaucoma patients and contact lens-wearers. They're the most accustomed to having their eyes poked frequently.

Once applanation tension is mastered, refraction should be next. It won't come easily to the new technician. She must first understand the anatomical differences between hyperopes and myopes and the effect of a cylindrical cornea on the manifest refraction. The more printed information she can read ahead of time, in addition to observing and questioning the lead tech, the faster she will learn. Ultimately, only through practice will it begin to make sense.

The experienced technicians should offer to help select the initial refractions. They can peruse previous visit notes to find patients whose refractions will likely be straightforward, such as teen-agers and patients in their 30s, and use those as the trainee's first cases.

Over time, she'll need to learn about myopic shifts and spherical equivalents. Shared experiences and suggestions from others will help her understand the effects of diseases on vision. It's a good move to assign a patient staffperson a mentoring role, explaining refractive changes as they occur. In addition, the new hire should be encouraged to review her refractions with more experienced personnel either before or after the physician encounter.

One of the best learning tools is for her to follow one patient that she's helped work-up through his examination, particularly if her work resulted in unusual findings. If it's not possible for her to be present in the examination room with the physician, every effort should be made to review his chart with her. Without this aspect of training, she may wonder why the autorefractor displayed +1.00 sphere, the refractive result was -0.75 sphere, and the patient only gained two lines of vision. She may think she made a mistake, when in actuality the patient's visually significant cataract is being scheduled for surgery.

Training should be ongoing

Every practice has down time. View it as an opportunity to advance the staff's clinical skills. Each office should have a library of books for the technical staff to reference. And if the practice doesn't have an in-house education program, every effort should be made to find courses that will enhance the staff's ophthalmic awareness. The Joint Commission of Allied Health Personnel in Ophthalmology (JCAHPO) maintains lists of regional educational programs on its Web site as well as links to related sites.

When you support the advancement of your technicians' skills and education, your return on investment is often years of loyalty from staff members. 

Jane Shuman, C.O.E., C.O.T., M.S.M., is manager of the Ophthalmology Department at Dedham Medical Associates in Dedham Mass. She's also Director of the Ophthalmic Assistant Program for the Massachusetts Society of Eye Physicians and Surgeons.