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Up Front | Sep 2009

Does Your Practice Need a Refractive Coordinator?

These staff members can benefit practices of any size.

The answer to the question posed in the title of this article is simple: Yes.

If you want to grow a successful refractive practice, a refractive coordinator (RC) is absolutely necessary. The chain of laser centers that I work with, EuroEyes, adopted the idea of using RCs from the large American laser center chains where the concept originated. This article addresses why you should think about implementing an RC in your refractive surgery practice.

In our practice, the RC is the link between the patient and the surgeon. In the past, staff people played many roles in our centers: receptionists answered the phones; secretaries wrote letters and handled billing; and nurses, technicians, or optometrists performed preliminary examinations before the patient saw the surgeon. We found that, in addition to these important functions, a refractive surgical practice needs one person to link the doctor and the patient in a professional way. This is the role of the RC.

The RC supervises and follows the patient through the refractive surgical experience, from the first contact with the clinic, through the examination process and surgery, and into the postop period. The RC knows the patient better than anyone else in the practice. He was the one who picked up the phone when the patient first called about having LASIK at our center. He greeted the patient when he walked through the door for the first time. He called to follow up with the patient who came in for a consultation but did not book surgery. These are all tasks for the RC.

Whatever size your refractive surgical practice is, your staff must be involved in the medical process—not by giving medical advice, but by being knowledgeable about the procedures and explaining to patients what they are about to experience. At EuroEyes, we attempt to teach our staff members how to perform pupillometry, corneal topography, wavefront aberrometry, and visual acuity examinations. That way, if patients have questions or are anxious about any procedure they are about to undergo, the staff can answer their questions intelligently and reassuringly.

Any staff member can become an RC, even nonmedical personnel. In fact, sometimes those with no medical training are more apt for the job. It depends on their personality and their ability to interact with patients in a friendly and professional manner.

Candidates for the position at EuroEyes receive on-the-job training, with both practical and theoretical components. This training lasts 1 year. In the practical sessions, we teach them how to answer the phone, talk and interact with patients, and perform the various preoperative tests. The most important lesson to impart is how to develop personal relationships with patients. The surgeon does not have the time to sit for 30 minutes with every patient; he needs someone else to develop that relationship from beginning to end. Patient-RC interaction is important.

Twice a month, the surgeon gives theoretical lectures to the RC candidates. These topics include anatomy, technical aspects of the refractive procedures, and how the excimer and femtosecond lasers and the microkeratome work. The training is treated seriously, with an official schedule and a book for the RC candidates to keep track of lessons and accomplishments.

At the end of training, the candidates are well prepared; their knowledge is deep, not superficial. This is important because modern patients are demanding. They have looked up procedures on the Internet and they want to know everything. Trainees must know the history of refractive surgery in case they encounter a patient who previously underwent radial keratotomy or another older procedure. RCs must know about forme fruste keratoconus because they must be able to explain to the patient early in the consultation process why a premium procedure may be necessary. They must know the difference between surface and lamellar procedures, between cornea- and lens-based procedures, between monovision and multifocal IOLs. They must know about the possible side effects of surgery so that they can reassure patients who call with worries postoperatively. If patients perceive that there are areas the RC is unfamiliar with, they will be less likely to put their trust in him.

The RC must also know what distinguishes your premium clinic from other clinics. He must know that you offer the most modern femtosecond and wavefront-driven technology, unlike the clinic across town still using older technologies. You do not want him to talk down your competitor. Instead you want him to explain, for each individual, why the premium product may be the best choice.

This is a new concept for doctors to accept—that patients can listen to information from nonmedical personnel. Again, these nonmedical personnel do not give medical advice to patients, but the RC must be familiar with and able to discuss the different options.

Training ends with a 1- or 2-day examination at EuroEyes headquarters in Hamburg, Germany, with a multiple-choice test and oral exams conducted by two EuroEyes ophthalmologists. There is a reward for success, and the RC gets a salary increase if he has done well in the training and passes the test. RCs may also be allowed to attend one or more professional meetings as part of their reward.

Practice styles in Germany and other countries in Western Europe fall into four general categories. Each type of practice can benefit from implementing an RC.

1. Most general ophthalmologists (ie, more than 80%) are conservative and do little surgery. For conservative ophthalmologists who want to start performing laser refractive surgery, we recommend that you attend refractive surgery courses, wet labs, and hands-on training, and perform your first cases under the supervision of an experienced surgeon. At the beginning, you may sublease space in another laser center. Even at this early stage, we believe you should start thinking about training one of your staff to be an RC. It is good to have someone in your practice other than you who knows about refractive surgery.

2. Approximately 10% to 15% of ophthalmologists have high-volume cataract surgical clinics and do cataract surgery on a referral basis. If you have a cataract surgical practice with a volume of 1,500 to 2,000 cataracts per year, you may be in an ideal position to establish a lens-based refractive surgery practice. As patients increasingly ask about multifocal IOLs, you may find that your chair time per patient increases dramatically. You cannot perform 1,500 cataracts a year and sit for an hour with every patient. Especially with baby boomers and more educated patients, you need a qualified person in your practice to sit with them and explain about how multifocals work, what the side effects are, and so on. In this situation, an RC is a must for you.

3. Single surgeon-owned laser centers. If you have an existing single laser center and perform mainly LASIK and refractive lens exchange, you may already have an RC. If you do not, you must ask yourself, what is your goal? Do you want to increase your volume? If you do, you need an RC who knows the theoretical and practical aspects of refractive surgery to help you grow the practice.

4. Commercial LASIK chains. If you are in a laser chain, such as EuroEyes or UltraLase, you undoubtedly already have one or more RCs. You cannot run a busy refractive practice with a volume of thousands of LASIKs a year without qualified RCs.

Our rule of thumb is that if you perform 50 to 80 cases a month, you need one RC. In a large clinic performing more than 50 cases per month, it may be a good idea to have one RC answering the phone and scheduling consultation appointments and a second RC meeting with patients and scheduling surgery.

Clinics performing more than 100 cases per month probably need at least three RCs. Even if your volume is less than 50 cases per month, an RC can be valuable, providing that constant communication link with your patients to promote your center's premium refractive surgery offerings.

We recommend choosing your first RC candidate from among your experienced staff. Bringing in new people to an existing team can cause hard feelings and friction. Choose someone whom you know and trust.

Then, make the choice official. Sit down with the candidate and explain the position and the training process. The program does not have to be a full year as it is at Euro Eyes; it can be 1 or 3 months or whatever you believe is appropriate. However, it should be a defined period ending with a written and oral test. The knowledge that there is a test at the end helps to motivate the RC candidate.

Becoming an RC should be seen as a career step. At our center, most staff members eventually become RCs. We want our personnel to be able to cover many tasks in the laser center. That way, if someone gets sick, another person can take over their work. Over the years, we offer every staff member the chance to become an RC.

Most medical practices in Europe do not compete for patients; they have waiting lists. Patients are used to waiting 3 or 4 hours in an ophthalmic practice. You do not want that to happen in your premium refractive surgery practice. But how do you explain that to the nurse who is used to patients waiting for 3 hours? How do you explain that, in your practice, you want patients to wait only 10 minutes or less? Sometimes it is valuable to hire someone from outside the practice who has worked for a hotel or a marketing company. We have had good experience with this approach.

In my opinion, a refractive surgery practice can survive only if it aims for the premium market. Some clinics offer basic LASIK at a discount price and little else. To distinguish your practice, you must provide the best quality procedures with premium results. You must remember that your patients are paying out of pocket, and they must receive first-class treatment, advice, and follow-up in your center.

To accomplish this, you need someone to help you educate the patient to select the premium procedure—not because you make more money, but because it is safer, more precise, and provides a better outcome for the patient. This is true for wavefront-guided LASIK with femtosecond flaps, premium IOLs, bioptics procedures; each offers a specific solution for specific patients, and each takes time to explain. You can do a lot of surgery and not be profitable, or you can do less surgery and have a premium practice with excellent outcomes.

Financing through the practice should be offered to all patients. Even if the patient does not ask, we suggest financing to every patient. This may allow patients who have set themselves a budget to upgrade to a more expensive premium procedure that we recommend for them. They can pay in cash the amount they have budgeted and finance the rest.

Remember that patient satisfaction is key to word-of-mouth referrals; that word-of-mouth reputation can keep your practice going, even in the depths of a recession. We have found that using the best technology to obtain the best results has been a strategy for success in our practice.

Wolf Eckhard Weingärtner, MD, FEBO, is the Medical Director of the EuroEyes Clinic, Stuttgart, Germany. Dr. Weingärtner states that he occasionally receives travel grants from Abbott Medical Optics Inc., but has no financial interest in the products or companies mentioned. He may be reached at e-mail: weingaertner@euroeyes.de.