Dr. Mai's Optometry Blog

Not optometry related as much business related.

Last weekend I went to Las Vegas, and in particular ate at a Restaurant called Bouchon‘s in the Venetian hotel. It was awesome, except pricey, but price isn’t the biggest factor when picking a restaurant in Vegas.

My friend Elaine orders a dish, but she ends up not liking it too much. The waitress notices immediately that she doesn’t like it and without prompting suggests that Elaine pick something else. Elaine doesn’t mind it so much and says no thanks.

Without us even asking, they take the entire dish off the bill. And Elaine gets free dessert.

Also, besides the fact that they had people watching the table nonstop to refill our waters when the glasses were even half empty, get this.

I went up to use the restroom and throw my cloth napkin without even thinking about it on the table. When I come back the waitress apparently had stopped by, and folded it into a neat pretty fan-looking thing! Wow I was impressed.

They say you can only win two of these three categories of price, quality, and service when running a business. Most private optometric practices will never win the price war, so don’t fight it. But if you can “wow” someone in the other 2 categories, they’ll keep coming back.

On campus today at noon, the professional eye care resource co-operative invited students to join them for lunch. This was the second time I joined the group for lunch, and they’ve always been an incredibly friendly group of people. PERC is an optometric co-opt comprised of individual practitioners who all gross over 1 million dollars annually.

Right now there are over 100 optometrists in the group, with the majority of them in Southern California.

There is evidence that the prevalence of myopia is increasing significantly over just the past few decades.

Rate of myopia increasing rapidly.

Looks like decent future job security for optometrists in the United States. The article (written in 2009 by Susan Vitale) states that 1999-2004 rates were 41% versus 25% when done in 1971-1972.

Interesting indeed!

Beginning July 26 optometrists can see Medi-Cal patients once more.

Check it out here

This is the first of many optometry clinical encounters where I learned something.

1. Very first patient ever in my life. (I don’t count seeing classmates/friends as first time experiences). 66 year old male contact lens patient who wants multifocals CLs. But he’s doing a modified monovision of sorts where he has a multifocal in one eye and a distance toric lens in the other. I fit him with the CIBA Air Optix Aqua Multifocals in his non-dominant eye and the CIBA Air Optix Toric Lens distance contact lens in his dominant. He LOVES the vision, reads happily and can see distance great and the over-refraction (loose lens in multifocal eye, and the distance I did a sphero- cyl OR through the phoropter) was about plano-ish in both eyes.

The clinical pearl is that modified monovision can be an excellent option for patients with a little bit of astigmatism (he had 1.25 D of cyl.) Especially if the patient loves the feel of a particular contact lens multifocal but a toric multifocal option isn’t available.

2. Very first primary care patient ever in my life . 83-year old Spanish speaking only patient comes in with one eye barely open. Chief complaint from his son (translator) is that his left eye is always nearly closed. 20/30 in his open (OD) eye, and light perception only (OS) in the eye that he barely keeps open.

Turns out he has a full-blown retinal detachment secondary to diabetic retinopathy that my partner Chad and I spot which our staff doctor confirms and congratulates us on. So what about the eyelids closing? The patient was able to lift that eye when he desired.

The retinal disparity caused by the retinal detachment between each eye made him voluntarily (and then just out of habit) close his non-seeing eye. This was not a case of ptosis.

3. Second contact lens patient ever. Female keratoconus in her 20s who has lost one gas permeable lens and needs a new one. Chad and I are at it again. Getting a crazy cover test of 20 exotropia in entrance testing. our staff doctor comments when we first meet with him with this clinical pearl:

“Don’t do a binocular test on an essentially monocular patient” (at this point she had just one CL on, and she can see hand motion only in the eye without the RGP.

Other clinical pearls was the patient was getting inferior dimple veiling on the cornea. To fix this we steepened the lens.

We steepened it to allow for better centration so that the lens would not slide down and we also reduced the optic zone diameter to decrease chances of air bubbles.

That’s it for now!

A classmate of mine made this video. It highlights some of the more lighthearted aspects of being an optometry student at SCCO. This was also shown at our spring open house for interested SCCO students.

My AOSA Trustee Dave sold me on going to optometry’s  meeting, so I went last week to the AOA optometry’s meeting in Orlando and boy was it an event. The Gaylord Hotel was enormous with multiple pools, bars, and a large convention center. There’s just something about a huge auditorium with two big screens showing the speaker and powerpoint presentation that is just cool in my opinion.

Highlights:

- Optometry super bowl (hosted by Essilor) . It was like a sporting event, people were chanting and screaming for 2 hours for their representative to show everyone who was the biggest nerd of all in a knowledge bowl optometry trivia match. Unfortunately, our guy Andy didn’t make it past the first round. Dr. Kevin Alexander, our president, was there and told us if we won the bowl he’d give the winner a full-ride scholarship – so I’m going to go for it next year!

- Went to a seminar by John Rumpakis, and A. Kabat about day to day dilemmas. It was similar to my case analysis classes and there were probably 500+ students in attendance.  Val and I were the only students to walk up to the presenter A. Kabat after the lecture to get his opinion on why he used Azasite for something in conjunction with oral doxycycline – though I forget what the condition was (ocular rosacea?).

- John Rumpakis and Ryan Parker had a presentation on private practice and the transition from student to doctor. They did something really ingenius to get participation by putting up their cell phone numbers for us to text questions and while the other person was talking they would read the text messages and answer the questions. They might have answered 20-30 in total and 2 of them were mine! I asked them who they thought would win, Lakers or Celtics, before the actual game and they were split. I also was confused at how Dr. Parker got his practice breaking even 2.5 months after starting cold without stealing patients from his former partner – he kind of shyly answered the question but Dr. Rumpakis called him on it and said he basically stole the patients lol. I guess in optometry, you gotta do what you gotta do.

- The receptions were a ton of fun. I met a bunch of other students from Berkeley to SUNY and thought everyone I met was super nice and easy to talk to. The future of the profession looks bright, I know this because nice people finish first in my opinion =).

- Practicing optometrists at the AOA convention love the profession and think it has a bright future. I kept hearing from the young and older docs “Congratulations! You joined a fantastic profession.” To be honest, it makes me feel great to hear such things.

- Some believe optometry  is oversaturated. “Get out of California, come to my neck of the woods.” Others (some of the hotshot consultants) think saturation is no big issue.

From optometric management

Clink on the link above to read an article about bringing a new grad into an established practice.

In psychology there is something called the self-serving bias. To quote from Wikipedia:

“A self-serving bias occurs when people attribute their successes to internal or personal factors but attribute their failures to situational factors beyond their control.” (wikipedia)

Not my fault, the DOG ate my homework!

This is prevalent in optometry school and no doubt with many other professional/graduate  schools. When it comes to test-taking, it seems to happen on every other test that there is a question that students miss yet inevitably blame the instructor for writing a poor test question.

Students sometimes start to think they’re always right, and refuse to listen and learn when they’re wrong. At my friend’s work, she laments often about coworkers who EVERYONE knows is at fault for a particular problem, yet that coworker is too prideful to admit they made a mistake and the politics of the matter makes life difficult to get things done.

So what’s the point of this post? It’s really just to say “don’t take yourself so seriously.” At SCCO they try to teach confidence in the clinic, to make a decision and stick to your guns. This is the right approach, but while learning always remain open to accept criticism for your mistakes.

One short anecdote I forgot to mention at the RAM.  My friend Denh was talking to Dr. Gordon, a staff doctor over at OCLA about ocular disease. It went something like this:

“Dr. Gordon! How much disease do you see at OCLA?!”

“Oh we see quite a bit, I guarantee you’ll learn a lot if you come here”

“Awesome! The more disease the better. We just learned about Trachoma in class yesterday, about ARLT’s line it was fun!”

:Chuckling: “A little knowledge can be a dangerous thing.”

I thought it was interesting what Dr. Gordon said, but he is right on the money. How many times do I expect to see Trachoma in the United States in my lifetime? Possibly ZERO times ever. It should very rarely be on my list of differentials. Inclusion bodies from Chlamydia, possible, but not Trachoma. So why do we learn it?

Some will fault optometry school, saying what’s the point of teaching all this “junk” information. Or mention that in a private practices someone shadowed, they never do phorometry on every single patient – so they’re mad that opt schools make us waste our time.

My opinion is that the point of optometry school is to learn as much as possible so that if I ever run across it, I can make the appropriate call. Definitely, it would be financial suicide to do 2 hour exams on all our patients when we graduate, but for now it is academic suicide to not practice all the skills we’ve been taught and to do a thorough (this is the emphasis, not speed) exam.

Most optometrists who have ever done a residency in optometry told me they were glad they did it. Many people who didn’t do one say they are glad they didn’t forfeit the extra year of earnings and that they felt adequately prepared to handle things with the training they received during optometry school.

So what should a third/fourth year optometry student to do? What are the pros and cons of doing a residency in optometry?

Let’s take a look at the pros and cons:

Pros of an optometry residency:

1. You do get paid, probably to the tune of $30-35,000. Not a lot, but that’s 2 times my current spending budget in optometry school so it’s an upgrade!

2. You get REALLY good at something that might have taken many years to get good at. How many keratoconus, prosthetic eye candidates, low vision, or strabismus would you see in private practice? In a residency you’d see multiple EVERYDAY. In saturated optometry markets, carving a specialty niche can be very beneficial. Word of mouth referrals for niche specialists spreads fast which will help your bottom line.

3. Don’t have a job lined up? Don’t know where you want to set up your practice? Remember, in optometry you can succeed as long as you avoid the train-wreck. Ducking away for 1 year gives you more time to shop around for practices, interview, and network with other optometrists to find that perfect opportunity – and not being unemployed. Who knows, maybe the residency itself will help you find a job or partner who requires your unique expertise. Regardless, it’ll give you more time to more carefully examine your post-grad options without leaping for an opportunity out of desperation. Like John Wooden, the famous UCLA basketball coach said, “be quick, but don’t hurry.”

4. Less need to refer because you are better trained. This keeps life more interesting when you can manage the more interesting cases.

5. If you plan on doing academia, teaching, or working in a hospital setting, then a residency needs to seriously be considered. Not only seriously considered, it might even be required.

6. You can apply and still withdraw if you change your mind (but only up to a certain point, afterward it is extremely bad form to not honor your commitment). So it doesn’t hurt to just apply up to a point. You never know what doors could have opened if you never gave it a shot.

7. Psychologically, it’s nice to know you’ve got something going on after you graduate rather than just twiddling your thumbs and nervously looking for fill-in work or a corporate gig after graduation.

8. You can still find fill-in work maybe a couple days a month if you choose to pad your income. I know of an SCCO resident who did just that.

9. Learning is fun. One of the major draws I had to going back to school after I graduated with my BS from UCLA was that I loved learning. In a work environment, you do learn some things here and there, but it’s not your JOB to simply learn. One of the fun things about a residency is that it is still mentored education. You’ve got more responsibilities and privileges, but it is still a learning experience.

10. Board certification passed last year at the AOA meeting. If your intention is to become board certified, I believe you get to leapfrog some of the time-requirements if you complete a residency. This could potentially be a great added benefit to doing a residency if board certification is mandated or looking very favorably on by insurance.

11. It is only one year, honestly.

Cons of an optometry residency:

1. You forfeit a year of real salary. Which can be significant if you’re tired of living life on strict financial restraint.

2. Applying for a residency is like applying to school again. You have to hunt for letters of rec and interview. Could be difficult if you never fostered meaningful relationships with your current faculty.

3. You might not end up geographically where you want to be. If you have a spouse or significant other, is it worth being apart for another year?

4. Not all residencies are created equal, you may end up just being at a “5th year” of optometry school.

5. You may feel already confident with your skill set and any future obstacles can be self-taught.

6. Once you start, you can’t jump ship in the middle of the year. Say you find a can’t miss opportunity, well you might have to wait until you are done with your residency and by then it might be too late. The practice you wanted was sold, the job opening was filled etc.

It’s much more common to hear about myopia at my age and less so with hyperopia. But the prevalence of hyperopia really struck me when I volunteered for Remote Area Medical last week. What is RAM? Basically it is an event where free healthcare is given to those who cannot afford it on their own.

I volunteered in the lab making glasses as well as dispensing them. With no stretch of the imagination, it seemed at least 75% of the glasses I made were for hyperopes. Some had it bad like +4.00 with a +2.00 add. It makes me wonder how long these people, who could not afford to update their glasses, have been functioning especially at close. With that much uncorrected hyperopia at near, I can’t imagine they could have been reading all that well.

Could the inability to read presently, and the accommodative demand manifesting as eye strain in their pre-presbyopic days have been a significant impact on their current financial plight? This is debatable but I would think it could have certainly impacted their performance in school and ability to learn due to a visual problem.

To me it just highlights the need to see an optometrist regularly. Undetected vision problems can certainly impact one’s ability to learn and just function. How many of these underprivileged people that RAM served could have avoided their situation altogether if they had proper eyecare at a young age?