Five things that make a great technician

I don’t want good technicians working in our clinic. There-now that I have your attention, let me continue.

I don’t want good technicians working in our clinic; I want the best technicians working in the clinic. Many people make the assumption that if they pass the JCAHPO, COA, COT, or COMT tests that they are good technicians. That might mean it would also be safe to say that the higher the certification, the better the technician.

Related: 7 tips for leaving a patient alone in the exam room

I do not believe that your certificate, or lack of certificate, is the true indication of what type of technician you actually are. There are so many intangibles involved in the mix. These skills are very hard to cultivate in a person, and it is very hard to evaluate whether someone might possess them during an interview.

There are five things you must know to be a quality technician:

1. Histories and vision

2. Refractometry

3. Pupils

4. Anterior chamber depth assessment

5. People skills

1A. Histories:

By nature, a history should be a series of specific questions linked together in an orderly sequence that continues to build on the patient’s response. The history is designed to paint a picture of the patient and his eye health.

These are the important parts of the history (in order):

• History of the chief complaint

• Medications and allergies

• Eye history

• General medical history (review of systems)

• Family history

The doctor’s exam builds off your history. Your exam and test planning (Does the patient need a brightness acuity test? Does she need a refraction? Does she need a visual field?) builds off your history. And billing is also largely based off your history. It is one of the most crucial parts of a technician’s job-but most technicians will tell you they hate taking histories and race through this process to get to the more interesting parts of the exam (refractometry and slit lamp).

Why do we dislike it so? Because patient’s ramble during their histories. We want them to give us their story in a small, Reader’s Digest-condensed version; the patient wants to share with us War and Peace.

Here are some tips:

• Keeping in mind patients want to tell their story, try to ask yes-or-no questions. If you ask, “So, tell me what happened with your eye,” he will begin the story at birth and continue until present day-often with information not pertinent to the problem.

• Put the chief complaint in their words. I have never had a patients come in and state, “I am having episodes of metamorphopsia x three days.” They say, “I am seeing floating mosquitoes this week.”

• When asking about allergies or medications, never carry that information forward in the patient’s record. Allergies need to be discussed at every visit. If a patient states he does not have an allergy, write: “Patient denies allergies.” The word “denies” implies that you asked the patient, and he said, “no.” The “universal no” symbol (circle with a slash) should not be used.

1B. Vision testing

If you are conducting an exam on a new patient, always check her vision with and without her correction. Some techs might think this is a waste of time, especially if the patient is seeing 20/20 with her current correction. Here’s a hint: not everyone wears their glasses. It is not uncommon to have spouses sharing a pair of glasses. While the patient may see 20/20, it is not really her correction.

If she is a returning patient, always look back at the last correction that was listed, as well as the last refraction the doctor ordered. We often wrongly assume that because the doctor gave her an Rx, she ran right out and got the new glasses. Be triply alert when working with nursing home patients. They might be wearing someone else’s glasses.

Here are some tips:

• Most of us use projected visual acuity charts. If a patient cannot see the “big E,” often a tech will then perform counting fingers (CF) testing at 10 feet or five feet. This is not the best measurement, and in insurance worlds, as well as sometimes the medical-legal world, CF is a lot different than 10/200.

If you use projectors, get a handheld block E to use if patients can’t see the big E.

• If a patient does not see 20/40 or better, always use a pinhole. Pinhole is a great cheat. If the patient’s vision improves, it gives you an idea that you might be able to improve her vision with a refraction. If she does not improve, the problem may be an ocular condition (macular degeneration, cataract, etc.).

• When testing children, always note if you, or a parent, is pointing at a letter on the chart. This is called semi blocking. Children will often see up to two lines better when someone is blocking or isolating letters for them to follow. Your doctor will want to know if this is occurring.

2. Refractometry

When I was learning refractometry, I was told the number-one sin was over-minusing a patient. Through the years, I have learned that actually the number-one sin is under-plussing a patient, followed closely by over-minusing. In both cases, these two sins occur for this main reason: you are listening too much to what patients want and not giving them what they need.

Common complaints with hyperopes:

• I used to love to read, but now I am so tired at the end of the day it’s no fun.

• I used to wear glasses when I was younger, but I outgrew it.

Hyperopic eyes are what I call martyr eyes. These patients need glasses, but their brain doesn’t want the help. So, the brain works and works to keep things in focus. They get tired, and some people even complain of headaches or upset stomach.

Be careful of listening too much to what he likes. He may need +3.50 D to correct his hyperopia, but his brain tells him he needs  -1.00 D. My personal best example of this: 34-year-old man came to our office five times in a year with the same complaints. He liked being a -3.00 D in the office, but he needed to be a +4.50 D.

Here are some tips:

• Pay attention to your auto refractor (or retinoscopy). If a patient’s auto refractor is -1.50 + 0.75 x 145, why are you giving him -3.50 +1.25 x 145? The answer is usually, “Because he liked it!”

• If it ain’t broke, don’t fix it. Pay attention to the patient’s vision. When the patient comes to clinic and states, “My vision is fine; I just want to get a new pair of glasses. These ones are a little scratched,” don’t make broad changes. She has no complaints and her vision is good. All she needs is a quick refinement.

• For every 0.25D you give a patient, he should improve a line (however, this doesn’t necessarily work with hyperopes).

Related: 3 correction options for presbyopes

3. Pupils

Pupils should be checked every time on all patients who are being dilated. Technicians will say, “But we just saw the patient three weeks ago, and her pupils were fine.” My response is always, “Between the last time you saw her and now, could that patient have had a stroke that no one knows about? Could she have a brain tumor that has suddenly manifested and no one knows about it?”

Here are some tips:

• Use a battery-operated transilluminator when you are checking pupils, not a disposable penlight. Penlights are variable, depending on the age of the penlight.

• Have someone in the office show you an afferent pupillary defect (APD) on the next patient who has one. Once you see it, you will never forget it.

• I tell my technicians to always assume that any patient with 20/100 vision or worse has an APD until proven otherwise. It doesn’t mean he actually does, but it will make you double-check his pupils because his vision is poor. Regardless of vision, always check those pupils well.

4. Anterior chamber assessment

Checking the anterior chamber depth prior to dilation ensures that the anterior chamber is deep enough that you will hopefully avoid an angle closure complication. Once again, technicians will tell me they just saw the patient two weeks ago and the angle was wide open, so they don’t need to check it again this week. This goes right along with pupils-a lot can change with a patient in two weeks.

We check every time because the pupil acts like an accordion. When you dilate the patient, her pupil will enlarge to allow more light in. The iris then gets pushed into the anterior chamber. If the anterior chamber depth is narrow to begin with, you may potentially cause a narrow-angle attack. This can also happen when the patient walks into a dark room.

Here are some tips:

• Do not use a penlight to check the anterior chamber. Have someone show you how to use the slit lamp to check the depth.

• Have someone show you what a narrow angle looks like. Again, once you see it you won’t forget it.

Related: Why keratometry is important 

5. People

Some of the most important skills technicians must have to be a great technician are empathy, sympathy, listening skills, ability to work in a team, ability to share and help others in the office grow in their fields, and finally, “wanna.” Wanna is the drive, the fire, the technician’s goal to want to be great, not just good. Some might call it passion or drive-I call it “wanna.”

These are the people skills that make a good technician great. Unfortunately, those skills can’t be taught. You either have them, or you don’t. In our office, I look for people who have good clinical skills, and then I look deeper to see where they will fit. Fit is everything to running a healthy clinic. You need the quality technical skills as well as the “fit” in your process of developing a great technician.

I challenge you now to do the following: read this article again, and pay attention to what it is saying. Then go look in the mirror and ask yourself the following question: Am I a good technician or a great technician? If you say “good,” what will you need to do to become great? You can do this!