Get Organized! Medical Office Organization Tips

This is an abbreviated version of my article, "Get Organized! Medical Office Organization Tips." Find the full article in the September/October 2018 issue of Administrative Eyecare Magazine!

Maintaining an organized office is the key to efficiency and sanity. These simple tips can improve efficiency, profitability, and decrease stress for everyone. 

Physician Productivity

In and out boxes: Consider placing them outside each doctors’ office so physicians can be productive during short period of downtime.

Staff Training, Processes and Protocols

Checklists: Critical positions to consider are check-in, check-out, and surgery scheduling.

Standardize each office position and doctors’ preferences.

Job protocols: Write a "how-to" manual for each job. When a staff member is suddenly unable to do his/her job, another staff member can pinch hit. Include all pertinent websites used along with passwords and log-on information. Include screen shots to walk the “pinch hitter” through computerized tasks. Give the manual pertaining to your job to the owner/doctor so it can be kept in a secure place. 

Desk areas

Cables: Use binder clips to organize power cords and cables. Label and color-code cables to indicate which cable plugs into which port in which piece of equipment. 

The Administrator

Bank deposits: Make daily deposits a priority. Online banking is a good solution, but regardless of whether or not you use online banking, the monies in the deposit don’t do the practice any good sitting in a drawer. 

Open-door policy: An open-door policy is great. It says, “I am always here for you.” However, it can adversely impact your productivity and handicap staff from problem solving on their own. Consider scheduling a one-hour “open door” slot each day. Communicate this to staff in a way that conveys that you value maintaining your own productivity. Be careful not to come across in a manner that implies the staff is “bothering” you.


Doctor preference sheets: When possible, standardize physician work-up protocols. If this is not possible, make a spreadsheet listing each physician and all preferred work-up components for each appointment type or situation. Identify with an "X" each component a particular doctor wants performed. Place this document o your server and shortcut to this document on each desktop and tablet. 

Reception area

Magazines: It’s difficult to keep magazines tidy. Placing them in decorative baskets eliminates having to straighten them and helps create an orderly yet inviting waiting area.

Refreshments: Consider placing beverages and snacks on a wheeled cart with brakes. This allows staff to roll the cart to the kitchen to wipe down the spills and replenish the cart efficiently. 

As you organize, purge unnecessary items so you are not organizing "garbage." Most people feel in control and satisfied when their space is organized. Organization clears your head, increases productivity, and decreases stress.

Short Staffed in the Clinic?

It's the same old story.  You're short staffed in the clinic and trained techs are difficult (or impossible) to find. Patients are waiting and doctors are running behind. Everyone is stressed!

You're not alone.  At least once a week I hear from practices just like yours looking for trained technicians.  I rarely have anyone to recommend to them.

Being short staffed is a real headache
There's a solution.  Train in-house (PS: It's easier than you think)

My clients requested it and it's here! A peer-reviewed, turn-key, customizable technician training program, ready for immediate implementation.    It's a one-time purchase; not a recurring subscription.  Utilizes the text "Ophthalmic Medical Assisting: An Independent Study Course" and your technician trainer.

This Technician Training Program Includes

  • 13 Training Video Modules fully narrated by Sharon Alamalhodaei, COMT, OSC and and Dr. Melissa Toyos, MD 

  • Original training videos of Sharon demonstrating techniques

  • Printed Quizzes and answers

  • Printed Trainer's Guide

  • Printed Trainee's Guide

  • A Technician Skills Assessment Grid

  • All future updates are provided to you for free

  • A one hour telephone implementation session with Sharon for your trainer(s) 


  • Reproducible training

  • Holds trainee and trainer accountable for demonstrating proficiency in each skill

  • Fully customizable

  • You can save, edit, print and share within your practice

  • Saves money: trainees are productive quickly


SALE Priced til August 31, 2017: $1,450

Click here to purchase

If you have been an in-office training client of Sharon's, please contact  for an additional discount available exclusively to her in-office clients  or 386-446-3884 



Why I Love Ophthalmic Medical Assisting

     Sharon with her students

    Sharon with her students

1. Learning new things every single day

2. Helping others see better which enriches their lives

3. We never do anything that hurts the patient

4. I love working with seniors!

5. Working with a team

6. Using high tech equipment which AMAZES me!

7. It's fast paced and the work is varied

8. Professional development (certification, sub-specialities such as retina, glaucoma)

9. Think of all the people walking around my town with spectacle prescriptions I helped find!

10.  It's the BEST KEPT SECRET!

PS Share the secret!

Strategies for Preparing for the COA Exam

                                    Sharon teaches subjective refraction in Texas

                                   Sharon teaches subjective refraction in Texas

Edit 7/17/18: Still looking for tips? Find an updated version of this article, with everything you need to know about the COA exam here

I am preparing for the COA exam - my first JCAHPO exam,  the most difficult part of the process for me is not knowing the depth or breadth to study in each content area. I constantly wonder "Am I over-studying? Am I understudying?  Am I studying the right things?".  - Sharon Alamalhodaei, 1993

Once you have taken your first JCAHPO exam, you have a better idea of how the questions and answers are phrased and the testing process as a whole.  Knowledge is power. Unfortunately, when it's your first JCAHPO exam you don't have this knowledge.   This, my friends is the real challenge of test preparation.

Strategy #1 Study Material & Prep Courses

Review the suggested reading material for the exam. Click on the link "Study Resources" here

Due to the cost, most people cannot purchase all of the study resources listed, so you must either select a few broad texts or be creative by leveraging as a group and buying and sharing books with colleagues. Even better, ask your practice to build a library of resources which you can 'check out'.  If you can only choose a few books here are my recommendations: 

1. Ophthalmic Medical Assisting: An Independent Study Course (Newmark, O'Hara) Any edition newer than a 4th edition will do and they are readily available used on Amazon. Unless you have attended a formal accredited Ophthalmic Training Program, this book and the test you can purchases separately is a prerequisite for the COA exam - so you need it regardless. 

2. The Ophthalmic Assistant (Stein, Slatt, Stein) Again, any recent edition will do and they are also readily available used on Amazon. The trick with this book is there is a TON of information in it that you don't need to know for the COA exam. So, refer to the test content areas and study just that content in this book.  Think "Basic Level Proficiency" and read to that depth and breadth

3. The COA Study Guide, available from JCAHPO is terrific. It's practice exam questions and is only $15. The depth and breadth of questions closely resembles what you'll see on the actual exam.

4. I teach in person COA Exam Prep Courses throughout the country.  Check here for more information and to see if I'm coming to your area soon.  I also teach an online COA Exam Prep Course which allows you access for 6 months. You can pause and re-review any part of it.  It includes a 200 Question practice exam plus individual tutoring with me. A free sneak peak is available here. You can click through a link below the sneak peek to purchase it.

4. Some people like using flash cards to study.  ATPO has a set for the COA exam which you can find here:  Flash Cards

Strategy #2 Find a new COA

Talk with colleagues who have recently taken the exam. JCAHPO does not permit one to share actual questions on the exam, but these colleagues can help guide you as to whether you're studying the right material and depth and breadth of material. 

Strategy #3 Study Buddies

Get a study buddy.  It' s much more fun joining forces with someone who is facing the same challenge you are.  It holds you accountable for progressing with your studying and you can quiz one another.  

Strategy #4 Break it Down

"How do you eat an elephant? "One bite at a time!"  

Set a  goal date to take the exam. For example, 6 months from now.  Then, divide up your study material accordingly.  For instance, if you're taking the exam in 6 months (26 weeks) divide up the study material into 20 sections. This leaves a little wiggle room in case something comes up in your life that precludes you from studying that week and leaves a week or two right before your exam for last minute review and memorizations. Then, stick with your study schedule.  

Strategy #5 Phone a Friend

Do you have physicians or senior techs who like to teach? Take advantage of their knowledge. Be inquisitive and ask questions about anything you study but don't understand.

Strategy #6 Join In

Join Ophthalmic Tech Facebook groups. One of my favorites is "Ophthalmic Techs on Facebook".  Like and Follow me on Facebook and Twitter at "Eye Tech Training". Subscribe to this blog where I post a wealth of information about technician skills and technique. 

You CAN do it if you put your mind to it! Please feel free to reach out to me if I can help you. My email is or message me on Twitter @EyeTechTraining or Facebook at "Eye Tech Training"

Your Date with Mr. Humphrey

Automated Visual Field Testing is critically important. It assesses the functioning of the entire visual system including the brain, optic nerves and retinas. Obtaining a reliable, quality test is the job of the visual field technician.  This article discusses the two keys to obtaining a quality test.

Key # 1: Instructions

How can you expect to get a quality test if you don't tell the patient what you want them to do? Patient Instruction is critical.

Following are bullet pointed instructions. I recommend you post them to the left side of your visual field screen so you can easily glance at them while instructing the patient.


 Patient Instructions

  • Test of side vision
  • Makes a map of vision
  • Chin in chin rest, forehead against bar
  • Look straight ahead at yellow light. Do not look away from the yellow light
  • You’ll see flashing lights. Some will be very bright, some very dim
  • Sometimes you won’t see a light for a short time - that’s normal
  • Push button whenever you see any light other than the yellow light
  • Keep chin in chin rest, forehead against bar
  • Do not move your head
  • Blink whenever you want
  • Remember to only look at the yellow light and push the button whenever you see any light other than the yellow light

Instructions for the Visual Field Technician

This test requires a partnership between the patient and the technician therefore, it's equally important the technician also knows what to do. Following are bullet pointed instructions for the technician: 

  • Place lens(es) in lens holder
  • If possible, align handle of lens supero-temporally
  • Patch eye not being tested
  • Confirm patient cannot see around patch
  • Give patient response button
  • Position patient
  • Height of table ok for pt?
  • Chin on chin rest
  • Teeth together
  • Forehead against bar
  • No head tilt or turn
  • “Can you see the yellow light in the center?”
  • If no, change fixation target small or large diamond target. Pt should fixate in middle of diamond
  • Align pupil in cross hairs on monitor screen

During the Test

 “Push the button whenever you see any light other than the yellow light”

Encourage patient but don't distract from test

  • You’re doing great
  • You’re almost done

For Fixation Losses

  • Remind patient to look only at yellow light
  • Is fellow eye fully patched?
  • Click ‘Retry to find blind spot”
  • Recheck patient's head and eye position
  • Goal: < 20% fixation losses

 Key # 2: Patient Positioning

If you're not sure how to fix a positioning problem, ask the patient to sit back, pull the patient's chair back and start from scratch with positioning the patient. Here are the important points:

  • Chin down, teeth together

  • Forehead against bar

  • Lens as close to eye as possible without eyelashes touching lens

  • Head straight (no tilt or turn)

  • The patient's chair should be aligned straight with the chin rest/VF machine

  • Pupil aligned in cross hairs


Yes, Visual Field Testing can be boring and arduous for the technician and for the patient, but if you carefully instruct your patient and closely observe the patient's positioning, you will be much more likely to obtain an accurate, quality test.  Your patient AND doctor will appreciate your efforts. 



How To Be A Better Tech

In order to become a better Ophthalmic Technician

 One must be

  1. Interested in what you're doing.... have passion!

  2. Willing to hear the truth about ones skill level and be objective about oneself.

  3. Willing to practice and reach outside ones comfort zone. 

To become great at anything, you must either:

  • Be born with innate talent
  • Develop proficiency in a teachable ability

Musical ability is sometimes thought of as an 'innate talent'. Ophthalmic Medical Assisting is not thought of this way, rather one develops ability as an Ophthalmic Tech through learning and targeted practice.

The Key Ingredient

Deliberate practice is aimed at improving specific aspects of the skill. Deliberate practice is very different from what many of us think of as 'practice', which is when we aim for vague, overall improvement. 

Deliberate practice requires feedback from someone who understands what adjustments need to be made to make you better at that skill; someone who already is proficient who then 'coaches' or teaches you how to develop those skills. 

Studies have shown that on average it takes 10,000 hours of deliberate practice to become highly proficient in any given skill.  10,000 hours is approximately five years of full time work in your clinic.

Push Yourself To Success!

You must reach outside your comfort zone as you practice in order to develop proficiency.  It's much like aerobic training. If you jog so that your heart rate is only slightly above your usual heart rate, you won't develop aerobic fitness. You must push yourself beyond that which is "comfortable" in order to develop aerobic fitness. 

Make a point to reach outside your comfort zone every day to learn skills and to become better at those skills you already have. Success is within your reach. Go and get it!


Newbie Training: Contradictions In Technique

 &nbsp; &nbsp; &nbsp; Becoming an Experienced "Baker"

      Becoming an Experienced "Baker"

When I Was a Newbie

I was new to the ophthalmology field.  I had a designated trainer who put me on the fast track to proficiency.  I became confused, though when colleagues would contradict what I was taught.

For example my trainer taught me to check vision repeatedly during a refraction. Colleagues told me I should only check vision when the refraction is complete.  My trainer taught me to isolate letters on the Snellen Eye Chart, but others told me to keep the chart open.   Was my trainer correct? Were my colleagues correct?  I was confused and began to doubt my trainer.  I worried I was doing things wrong. 

What I Did Not Know  

I did not know that there's more than one way to skin a cat. (I so hate that saying, but it's most appropriate in this circumstance).  My trainer and my colleagues were both right.  

It's difficult being a new trainee and when you add multiple opinions to the mix it is even more difficult.  I encourage techs to avoid giving advice to trainees. Instead defer to the trainer (even if you'd do things differently).  It will likely only add to the newbie's confusion, not add to their proficiency.  

Learning To Bake a Cake

A new baker follows the recipe as it is written because he doesn't have the knowledge to or an opinion about changing the recipe.  However, once the baker has made the cake a number of times, he might decide to add nuts or substitute caramel for chocolate.  The cake will still turn out tasty even when those ingredients are changed.  However, what would happen if the baker changed ingredients like yeast or flour?  

An experienced baker knows what ingredients he can tweak and what he shouldn't change. A new baker doesn't have the experience to know this so he should follow the recipe as it is written.    

The Experienced Tech

Once the Ophthalmic Assistant gains experience, she learns what parts of her work up can be tweaked and what should never be changed.  She is now an "experienced baker" and can add all the nuts she wants to her cake!

Managing Test Anxiety


Test anxiety

I don't consider test anxiety a bad thing.  It means you care about doing well on your exam which is a good thing! The trick is to harness and manage this anxiety for your benefit.

Yes, it's important to study, cram, memorize.  But it's equally important to manage test anxiety so you can retrieve that critical information. Some methods for managing test anxiety which have worked for me include

  • Exercise
  • Nurturing oneself (mani, pedi, etc)
  • Recreational TV watching and reading (not text books)
  • Meditation
  • Getting quality sleep   
  • Preparation (studying appropriate test prep material)

Choosing Test Prep Material

People learn differently, so a method that works for your friend or colleague may not work for you. Perhaps you prefer using flash cards or online courses. Perhaps you prefer studying alone or maybe in a study group. Be open to trying new methods of learning. Prepare by using whatever method works for you.  

Know when to say when.  If you're studying and feel like you can't put one more thing into your head without something else falling out, close the books and walk away. 

In a Nutshell 

It's not a matter of not having butterflies, it's a matter of getting the butterflies to fly in formation. 

2016 Changes to JCAHPO Core Certification Exams

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Edit: You can find an updated version of this blogpost here

Approximately every five years JCAHPO updates the content for the COA, COT and COMT certification exams. These changes keep the certifications relevant and reflect respnses to periodic surveys about the tasks Allied Ophthalmic Personnel perform day to day in the clinic.

Currently, the core exams are divided into NINETEEN separate content areas including

  • Pharmacology
  • Ocular Motility
  • Lensometry
  • Ophthalmic Imaging
  • Visual Fields ...and more.

This will change in August of 2016.  The exams will be re-categorized into just FIVE content areas which will include the old test content plus additional content areas. These five core areas are:

  • Assessments (includes Visual Fields, Motility, Visual Assessment, History Taking, Refractometry and Refinement, Retinoscopy, Pupils, Lensometry, Keratometry, Biometry and Supplemental Testing)
  • Assisting with Interventions and Procedures (Includes Microbiology, Pharmacology, Surgical Assisting and Ophthalmic Patient Services & Education)
  • Corrective Lenses (Includes Optics, Spectacles and Contact Lenses)
  • Imaging (Includes Imaging, Photography and Videography)
  • Office Responsibilities (Includes Equipment Maintenance & Calibration, Medical Ethics, Legal and Regulatory Issues, Communication Skills and Administrative Duties)

If you're preparing for a JCAHPO certification exam, now is the time to decide if you want to take the exam before or after August, 2016. To help you prepare, JCAHPO and I have partnered to bring you COA & COT Exam Prep Courses. See a free sneak peek on this website on the 'Online Courses' page. The course content will be updated in time for the August, 2016 changes.


What I Wish I Knew When I Started in Ophthalmology

  &nbsp; &nbsp;&nbsp;


1. You can't refract every patient to 20/20 so don't automatically blame your refracting skills if the patient doesn't achieve 20/20.

2. When offered an opportunity to progress in your career - take it.  Even if it's not what YOU think you want to do. It could lead to other opportunities in the future. 

3. Don't worry about what your coworkers say or do..  It speaks more about them than it does about you.  It's just not worth the energy.

4. Avoid gossip and drama.

5. No matter how much you love your career always strive to maintain a work/life balance. 

6. Don't get complacent. Embrace mastering new technology and instruments that are introduced into the practice.

7. Give your boss more than s/he expects of  you.

8. Never stop reading.

9. Get involved in the ophthalmology community through continuing education and volunteer opportunities

10. Always remember the patient is a person... not just a set of eyeballs. 


Top Ten Things an Ophthalmic Technician Would NEVER Say to a Patient

 &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; Another day at the office.

            Another day at the office.

10. No... really... take your time on that cell phone call.

9. I'm going to check your pressure.  Squeeze your eyes really tight.

8. Those glasses you bought on the internet are PERFECT for you!

7. Tell me more about your hammer toe surgery.

6. Using that coat hanger to keep your glasses on your head is a GREAT idea!

5. It's fine that you came in an hour late for your 11 am appt.  I'm on a diet anyway.

4. Your vision is 20/400 OU.  Oh, by the way, can I catch a  ride home with you?

3. Yes, ALL of your family members should join us!

2. Yes, we really DO take the eye out when we do cataract surgery.

1. Don't tell me which is clearest.  I just want to SHOW the lenses to you. 

Taking Charge in the Exam Lane


Managing encounters with patients is both an art and a skill.  Either you run the encounter or the encounter will run you.  This is frequently one of the most difficult skills for new technicians to master. Conflicting Goals?

It seems we have competing interests: On one hand,;we strive to provide a welcoming and friendly demeanor, yet there are real time constraints dictated by appointment templates. Is this a no win situation?    I have found there are ways to satisfy both customer service and time constraints.

How to Manage Your Encounter with Finesse

Have you ever worked up a patient who wanted to engage in seemingly endless social conversations? What about the patient who won't stop joking around?  A simple yet effective way to get your encounter back on track without offending the patient is to say "Mrs. Smith, the doctor is probably wondering where you are. Let's get finished up so we can get you in to see him."  This is TRUE! The doctor probably IS wondering where your patient is. He is probably standing in the back hall looking at his schedule and wondering why he has yet to see Mrs. Smith whose short follow up appointment was 45 minutes ago!  The statement will not offend your patient; if anything, it may flatter them... ("Dr. Jones is looking for me and wondering where I am!").  I have used this technique many times over the years and it has worked without fail.

If you don't manage your encounter, it will manage YOU.  Take charge (but in a nice way).

COMT Exam: How I Prepared


More than twenty years ago; fresh in the field, I confided to a COMT that one day I, too wanted to be a COMT.  She scoffed and said "You can't possibly have enough knowledge to pass the exam unless you work in a large University Clinical setting or go to a formal COMT level training program."  I was bummed but I never let go of my dream.  In 2013, I became a COMT and proved her wrong. The day I took and passed my COMT Skills exam was one of the happiest days of my life.  Here are before and after pictures of that day...


I am here to tell you that YOU CAN become a COMT if you work hard enough and want it bad enough. Here's how I did it:  

  1.  I purchased or borrowed every book I could on JCAHPO's recommended reading list and read them each multiple times.   I studied for two full years for the exam. Six months before the exam I gave up all recreational reading material and TV, signed off of Words with Friends and Facebook and spent all of my spare time studying. I even kept a book in my car so if I found myself stuck in traffic I could use the time to read.  
  2. I went to JCAHPO's ACE meeting (the annual CE meeting held in conjunction with the AAO meeting) and took only Master's Level classes concentrating on subject which I felt were my weakest. If you get an opportunity to attend, I highly recommend the course on Clinical Mathematics by Kenneth Woodward, COMT. 
  3. I attended the COMT Review course at the ACE meeting but did not find it helpful. It is a REVIEW course. A Review course is a brief overview of the topics on which you will be tested. It doesn't actually give you the information in the content areas you need to know.  In contrast, a PREP course is a long, comprehensive course and actually gives you all the information you need to know to pass the test.
  4. Every spare minute I studied.I DID find JCAHPO's COMT Skills Review Course very helpful.  They had a team of COMT's who helped the group of COMT hopefuls as we went through various skills stations. They had stations on FA's, Motility, Lensometry and more.  The instructors were wonderful in explaining the skills and the pathology we were looking for. It was immensely helpful!
  5.  I found two mentors, Jessica Barr, COMT from PA and Sergina Flaherty, COMT from Texas who were helpful in answering questions I had about various pathologies and skills.
  6. I purchased several JCAHPO's Learning Systems modules and other CE courses on These complemented the Masters Level courses I had taken at  the ACE meeting. I especially found the motility courses helpful. 
  7. I wrote all the optics formulas I needed to know for the exam in a notebook and studied that the morning of my exam so it would be fresh in my head.

I scheduled my written exam for a Wednesday afternoon.  My plan was to spend Monday and Tuesday cramming and Wednesday morning studying my optics formulas.   On Monday morning I sat down to read and thought "If I put one more thing in my head something else is going to fall out!"  My brain was saturated.  I was also a growing more and more anxious.  That was when I decided to close the books. Instead of studying, I spent that Monday and Tuesday nurturing myself. I got a pedi and mani, went to a movie, watched dumb TV and got lots of rest. The helped my anxiety level be manageable.  On Wednesday morning, I went to the test site four hours early, found a nearby coffee shop with wifi and studied my formulas.  I took my exam and finished in just 1 1/2 hours. I had aced the test!    YOU can do it too!!! 

How to Deal With Conflict in the Office

Conflict is one of the toughest issues one has to deal with in the office. Business bring people together from many different backgrounds. This is good because varying experiences and capabilities enhance the efforts of the team.  However, the differences in and variety of people and experiences can cause conflicts to arise.

Strong leadership evokes respect, authority and a sense of grace.  When leadership is lacking, resentments arise. Trust is essential for any work environment.  Divisiveness, back-biting and internal politics can lead to distrust causing morale and essential  office functions can go downhill fast.

By the same token, a manager's job is not to simply resolve employees' conflicts.  It is to ensure that everyone is respected and understood.  Staff members should be empowered by management to resolve conflict among themselves in a mature, "grown up" way.

Here are some strategies to resolve conflict:  

  1. Ask yourself "Could this reaction be caused by something else?". For example, perhaps the other person has a sick family member and isn't responding to you as she normally would due to these personal circumstances.
  2.  Restate your position politely and respectfully. Avoid being defensive or seeming to    grind your heels in.  This provides the opportunity  to correct misunderstandings.
  3.  Mentally separate the people from the problem.  Realize that most people have good  intentions and aren't trying to cause conflict.  Give others the benefit of the doubt.  Separating the issue from the person helps to maintain good relationships once the  conflict is resolved.
  4. Listen and try to understand the other party's point of view.  Listen first, talk second and be open minded.
  5. Discuss observable FACTS (no opinions or suppositions).
  6. 6. Explore resolutions together and be open to the fact that a third option (other than your opposing positions) may be the best option.

The keys to successfully resolving conflict in the workplace are to be non-confrontational, open minded and respectful and when this happens, everyone wins!

How I Saved a Practice Tens of Thousands of Dollars

download (2)The administrator called me asking for help. She said her doctors had been getting a lot of glasses remakes and unhappy optical patients. Additionally, the doctors had lost faith in their technicians' VA's and IOPs measured with a Goldmann Applanation Tonometer.  The doctors and administrator were befuddled because their 30+ technicians had been doing well but seemed to have faltered over the past year.  They asked me to come to their office and spend three days with their technicians. Evaluating the Problems

I began by simply observing each technician as they processed patients. This took a full day given the fact that there were more than thirty technicians, but by the end of the first day I knew exactly what the problems were.  What I discovered is that a technician with many years experience  had been hired a year prior and had been put in the role of head technician and trainer. Unfortunately, this technician was not as well skilled as she (or the practice) thought she was. She had spent the past year re-teaching all of the technicians erroneous skills.


This practice worked in plus cylinder but the technicians had been trained to 'chase the red' (!) This one error was perpetuated from technician to technician until only spherical patients were getting accurate refractions.  Additionally, the technicians were measuring VA incorrectly. They recorded VA as the last line of letters they read all of the letters easily. The technicians were also taught to align the Goldmann applantion tonometer mires into the shape of an 'S' rather than 'just kissing' resulting in erroneously low IOPs.

Light Bulb Moments

I spent the next two days re-training the technicians on VA, refraction and GAT and by the end of the third day, they were all accurately refracting, measuring VA and GAT. The technicians had many 'light bulb moments' and It was a happy ending for everyone except the head technician who unfortunately, was demoted from that position. It was sad, but necessary.

My Two Cents

When you're new to the field, you only know what you're taught. If you're taught incorrectly you won't KNOW you've been taught incorrectly. This is why it's critically important to ensure technician trainers know their stuff.  Don't be shy about doing 'working interviews' with even the most seasoned technician. It's the only way to be sure they have good skills.

When you assign a lead tech or technician trainer, TRAIN THE TRAINER.  Ensure this trainer gets support from the practice in the form of continuing education and feedback and mentoring from the physicians.

A Happy Ending

In the end, the fixes for this practice were easy, but it took an outside person who could devote the time to evaluating each technician's work up to find the root of the problem. I called the administrator a few weeks later and asked how the clinic was going.  She said the doctors were thrilled with the quality of the technicians' work and their glasses remakes were down dramatically and the technicians said they felt more confident in their skills. She told me they estimated my services had saved the practice 'tens of thousands' of dollars.   That was great to hear... but the best part for me?  Better patient care. 

"Difficult" Refractions

phoropter (4)Most refractions are straight-forward but what happens when you're faced with one that's not?  Knowledge is power. With the proper training and guidance you can handle even the most challenging  refractions. Let's discuss some common challenges you may face and how to meet them head on. First, let's learn an important formula to know when scrutinizing your refraction. Generally, a one diopter change in spherical equivalent should equal approximately three lines of improved VA on the Snellen eye chart. A spherical equivalent is calculated by taking half of the cylinder and adding it to the sphere power, then dropping the cyl and axis.  For example, the spherical equivalent of -1.00 +1.00 x 180 is -0.50.

Patient Refracts To a Lot More Plus Cyl AND a Lot More Minus Sphere:                  Probable Cause:  Too much minus sphere, inaccurate refraction.                                                        Try This: Decrease spherical equivalent (0.25 sph to each 0.50 cyl)                                            Example:  WRx: plano +1.00 x 180 20/30   MRx: -2.50 +3.00 x 180 20/20

Explanation: This refraction doesn't make sense.  The spherical equivalent of this patient's WRx is +0.50. The spherical equivalent of their MRx is -1.00. They have only 2 lines of improvement on the chart with 1.50 D change in spherical equivalent.  You wouldn't expect that big a change in Rx for only two lines improvement of VA.

What to Do:  Decrease the spherical equivalent until BVA is obtained.  This is accomplished by removing +0.50 cyl and 0.25 sphere at the same time and checking VA after each change of the lenses.  The end point is when you determine the least change in spherical equivalent which gives the best VA.  Then, recalculate the change in spherical equivalent vs. the improvement in VA and see if it makes sense.

Patient Refracts to  > 3.00 D Difference Between Their Two Eyes.                                                Probably Cause: Anisometropia                                                                                                                    Try This: With both of patient's eyes open: Show pt changes in sphere of 0.50 or pulling sensation in RF increments so that both eyes’ sph powers are brought closer together.  Example: Pt refracts to:  -3.00 +1.00 x 180 OD   +1.00 +1.00 x 180 OS                                                                     Show the pt:   - 2.50 +1.00 x 180 OD   +0.50 +1.00 x 180 OS                                                  Ask the patient to compare this Rx with the refracted Rx.   “Does this lens look about the same?” Remember to show them binocularly - not monocularly.  Recheck binocular VA.

Explanation: Anisometropia means the patient has > 3D difference in refractive errors between their two eyes. Minus lenses minimize images, plus lenses magnify them. Patients who have anisometropia may have a difference in perceived image size known as anesekonia. Our brains can only fuse images that are of similar size, so when the patient has anisometropia they may have double vision or a pulling sensation.

What To Do: Give the patient the Rx which gives them the sharpest vision possible without causing a pulling sensation or diplopia.  It's critical to trial frame the new Rx. Be certain to center the lenses in the trial frame so the patient is looking through the optical center to avoid induced prism. With the trial frame on, encourage the patient wander around the office and look outdoors to make sure they don't have any diplopia or pulling sensation in the Rx.


Every refraction is a learning opportunity for the technician. Follow up with your doctor after he or she sees these challenging refractions and ask the doctor why he Rx'd what he did so you can learn from it. With practice and exposure to many different types of special situations you will become a seasoned refractionist. Happy Refracting!

Why Refract?

I prepared to refract my patient, Mrs. Turner who had just read 20/70 but she refused.  "I'm not getting new glasses" she said,  "I just want the doctor to check my cataract."  phoropter (2) Why Refract?

There are many reasons we refract patients. Some are obvious. The patient wants new glasses or contact lenses. Others are not so obvious.

Doctors can detect, follow the progression or improvement of certain eye diseases by measuring best corrected vision.   For example,  the primary symptom of macular edema is decreased VA so patients who are being followed for macular edema should be refracted to determine what their best corrected VA is since this is a direct indicator of whether the disease is improving or worsening.

The Role of the Ophthalmic Technician in Patient Education

Patient Education is key. When your patient refuses a refraction yet clearly doesn't understand the purpose for the refraction, it's up to the technician to educate the patient. I encountered this with my patient, Mrs. Turner.

"Mrs. Turner,  the reason we are doing this test is so the doctor can determine what your best vision is - not necessarily to prescribe new glasses.  This is important so the doctor can determine if your cataracts are indeed the cause of your decreased vision."  Once I explained this, Mrs. Turner was amenable to having a refraction performed and my doctor had all of the information he needed to make medical decisions which benefited Mrs. Turner.  

Your Role in Patient Satisfaction

download Your job security is directly related to your practice's success and your practice's success is directly related to patient satisfaction. Therefore, your job security is related to your patients' satisfaction. 

How can you contribute to patient satisfaction?

Efficiency  No one enjoys waiting.  A study done recently found that patient satisfaction correlates with wait time. The study found "Minimizing the time patients spend waiting to see a provider can result in higher overall patient satisfaction scores" *

Go the Extra Mile Give patients more than they expect. For instance, if it's pouring rain outside and a patient doesn't have an umbrella, offer to walk them to their car with an office umbrella.  It's the little things that mean a lot.

Use Positive Language  Instead of saying "I don't know" say "I'll find out".  Instead of "I can't do that - it's against our policy" say "Here's what I CAN do for you..."  

Be "On Stage"  You're at a work place, not a social occasion. When you are anywhere a patient can see or hear you be 'on stage". This means you have a professional demeanor and keep conversations and actions patient centered. When you're "off stage" (out of patient's hearing or sight) it's okay to let your hair down.

Avoid Calling Patients Pet Names like "honey" "dear" or "sweetie".  Some patients may be offended or feel patronized by these names. Terms of endearment should be reserved for close friends and family, not patients.

Work as a Team Avoid gossip and conflict with coworkers.  When everyone works together and pitches in to help each other out for the common goal of patient satisfaction work is seamless and both job satisfaction and patient satisfaction soars! It's a beautiful thing when everyone works as a team toward a common goal.


Rising Through the Ranks

Whether one is a natural born leader or has been identified as having the potential for developing leadership skills, it can be a challenge rising through the ranks. Typically the most difficult aspect is gaining acceptance from those you lead. What Your Staff Will Want to Know:


I rose through the ranks and found myself supervising technicians who had been at the practice many years more than I. Immediately after the staff meeting at which my promotion was announced, one of the technicians who I was now supervising approached me and said "Nothing is going to change - right?". Her question brings to light what most staff members' primary concern is: how the changes will affect them. Yes, things WILL change - not just for your colleagues but also for you. Be prepared for your actions to be scrutinized and for resentment by some.

What You Can Do

Work on developing your leadership skills by:

1. Finding a mentor who has been successful in positions of leadership.

2. Read books on leadership such as Dale Carnegie's  "How To Win Friends and Influence People" and Stephen Covey's  "7 Habits of Highly Successful People".

3. Praise publicly, correct privately.

4. After you have been in your position for 6-12 months, ask your staff for feedback about how you're doing.  Make surveys which allow staff to respond anonymously. Then, be open to what they have to say.

5. Be honest if you are still refining your leadership skills. Others will understand that. You will may mistakes and when you do, apologize to those involved. Learn from your mistakes and move on. Don't beat yourself up.

6. Keep your ego in check and be humble. Elevate and encourage your staff. Leaders don't need to prove they're better than anyone else. Be a king among kings rather than a king among paupers!  Your job is to develop others to their fullest potential.

7. Hold people accountable. Nothing drags team morale down faster than when someone isn't doing their job and then isn't called out on it by a supervisor. This DOESN'T mean that you call them out publicly. It means holding everyone accountable in doing their job and doing it to the best of their ability.

The Journey

Life is a journey of learning and new experiences.  Professional development can be a wonderful part of life so embrace your new position, be humble and always keep your staff's and the practice's best interests foremost in your mind.

Strategies to Excel in the COT Skills Test

images  The COT Certification testing process includes two key evaluations; a written test and a skills evaluation. The written test is multiple choice computerized exam. The skills test is a simulated virtual environment in which the candidate must perform 7 key skills. The COT candidate must successfully pass the written portion before being eligible to take the skills test.  The candidate has one year following the written exam to successfully complete the skills portion of the test. The  Skills Test includes:

  • Retinoscopy (plus or minus cyl)
  • Refraction (plus or minus cyl)
  • Manual lensometry (plus or minus cyl)
  • Ophthalmometry (Keratometry)
  • EOM evaluation including cover tests
  • Goldmann Applantion Tonometry
  • Humphrey Visual Field

How to Prepare

After you pass the written portion of the exam, JCAHPO will send you a list of the skills you must perform and a list of steps you must perform for each skill and the order in which you must perform the steps.  MEMORIZE THE STEPS ON THIS LIST.  They will also send you a pdf with screen shots of the computer interface. This will teach you how to interact with the computer interface, how to open and close drawers, turn on room lights, instruct the patient, grab equipment, submit your skill and more.  GO THROUGH THIS PDF MULTIPLE TIMES.

Also, consider purchasing JCAHPO Learning Systems modules that you need for each skill.  You only need to buy the modules with which you feel you need help. These modules are very similar to the computer interface you will use for the actual exam so they will not only prepare you for the skill, but also help you become more comfortable with the computer interface.  These modules aren't expensive and include CE credit, which you need anyway.

How It's Scored

JCAHPO will score you on two key components of each skill: Accuracy and Technique.  For example, when performing GAT, you will be scored on how accurate your TA is and also how you performed the skill. For instance, don't go on and off and on and off the cornea multiple times as you align your tonometer prism because you will be counted down in technique for that.  You want to approach the cornea in the approximate alignment you need and then make small adjustments to position to tonometer correctly.

You will have one hour to perform all of the skills.  You can decide which skills you perform first. If you are in the middle of a skill and forgot a step or feel like you made a mistake, you can restart the skill and the computer will 'forget' everything you've done on that skill. Once you 'submit' the skill and move on to the next skill you will NOT be able to make any changes to any previous skills.

Learning Your Results

JCAHPO will notify you within a few weeks via email about your results.  If you have successfully passed each skill (technique and accuracy), you are a new COT! Congratulations!  If you successfully complete some but not all of the skills, you will have a conditional pass and another opportunity to pass the skills you didn't successfully perform the first time.

A last tip: your new credential will be posted on your JCAHPO account before you receive the written notification, so if you just can't wait for the mailman, log onto your JCAHPO acct about 7-10 days after your exam and take a peek. Good luck!