Introduction and history
Ophthalmic assistants are essential members of the ophthalmologist-led eye care team ( Fig. 50.1 ). In an informal way, ophthalmic assistants have functioned for as long as there have been ophthalmic offices.
Although the ophthalmologist authorizes and always directs activities in his or her professional capacity, the ophthalmologist relies on the ophthalmic assistant to serve as a liaison between the doctor and the patient. The ophthalmic assistant’s function and role may be broad as well as specialized. Assistants are well-skilled and specially trained to aid ophthalmologists in delivering high quality patient care.
Until the late 1950s, ophthalmic assistants were an unorganized and uncertified group of individuals who assisted ophthalmologists in their day-to-day technical activities. Ophthalmologists provided a major role as mentor to the ophthalmic assistant. Training standards and efficiency varied greatly and depended heavily on the talents of the individual assistant, and the teaching ability of the supervising ophthalmologist. Ophthalmic assistants have been allied to ophthalmologists in offices and hospitals. No credentialing was required.
Formal academic programs, rather than on-the-job training, have been established in Canadian and American universities and colleges during this time, and official textbooks have been written that have been accepted, indeed welcomed, by both the Canadian and American ophthalmologic associations.
In 1962 in the province of Ontario, Canada, the government began requesting formal information regarding manpower and service to patients. Governments were being pressured to legislate that ophthalmologists perform only surgery, and nonmedical practitioners perform medical work and refractions. Ophthalmology leaders explained to the government that although there were many more optometrists than ophthalmic surgeons, an ophthalmologist had available a large resource in allied groups of ophthalmic assistants available to deliver eye care. The ophthalmologists performed surveys which found at that time, in Ontario, that there were at least two or three ophthalmic assistants to every ophthalmologist in practice. These assistants were formed into an organized group to aid in eye care delivery, which was the beginning of the formalization of the role for ophthalmic technicians.
In the early 1960s in Ontario, Drs. Harold Stein and Bernard Slatt organized instructional short courses and provided credit for examination for existing ophthalmic personnel. Drs. William Hunter and Stein formed an association of ophthalmic assistants to provide recognition of their special skill set, with membership certificates and pins. This eventually developed into the Canadian Society of Ophthalmic Personnel (CSOMP), which was a forerunner of similar societies, such as the Association of Technical Personnel in Ophthalmology (ATPO).
Along with Ms. Debra Kaplan, in the late 1960s, formal training courses were started at the Centennial College of Applied Arts, Scarborough, Ontario, Canada. The course ran daytime for 6 weeks. After graduating 35 ophthalmic assistants from this intensive course, they encountered difficulty in finding employment with ophthalmologists for the technical graduates. Consequently, the training program was shifted to evenings and only granted admission to ophthalmic assistants who were already employed by an ophthalmologist. This evening educational program, held once weekly, has continued in Toronto since 1965, and has been highly successful.
Centennial College in Toronto, and the Southern Alberta Institute of Technology (SAIT) in Calgary, Alberta started a home study course for ophthalmic assistants working for ophthalmologists across Canada. The course updated their skills; a graduate was given a “certificate of completion”, but there was no formal licensing required or other academic qualification.
In 1968 Dr. Bernard Sakler of Cincinnati asked Dr. Stein to present at the American Association of Ophthalmology (AAO) annual meeting. Dr. Stein presented on Canada’s development of allied health personnel’s training programs. His statistics demonstrated that there were many ophthalmologists and ophthalmic assistants sufficient to service the eye care needs of the Ontario’s population.
The AAO accepted this concept and began a program similar to Ontario. Drs. Slatt and Stein were asked by the AAO to begin a home study course for technicians, which advertised across the United States to upgrade the skills of ophthalmic assistants in offices. Dr. Stein eventually became the chairman of the House of Delegates for the AAO. Under the executive director at the time, Mr. Larry Zupan, this ophthalmic assistant home study course was a landmark success for the AAO. Eventually, the American Academy of Ophthalmology adopted the American Association of Ophthalmology as their council, with delegates from across the United States.
Concurrently with these events, Drs. Slatt and Stein coauthored the first clinical textbook for allied health personnel in ophthalmology, entitled The Ophthalmic Assistant , published by the CV Mosby Company, in 1968. It is now in its 11th edition and is accepted worldwide as a standard for ophthalmic technician education.
In 1968 Drs. Hugh Monahan and Peter Evans, established the Joint Commission on Allied Health Personnel in Ophthalmology (JCAHPO) with three delegates from each of the major ophthalmology organizations and the American Medical Association in Canada and the United States being represented. JCAHPO developed examinations and certification for a more senior level called the ophthalmic technician and the ophthalmic medical technologist. JCAHPO’s annual continuing education program became the largest and leading nonacademic education program to train ophthalmic assistants, technicians, and medical technologists.
Nature of the work
In North America, the main role of the ophthalmic assistant is to help the ophthalmologist in patient care. The assistant is responsible for taking the patient’s history and conducting the preliminary patient eye examination, for maintaining sterile equipment in the office, and assisting in minor surgical duties. Another key role is to provide patient education.
The ophthalmic assistant performs many diagnostic technical tests, including assessing vision, visual fields, pupillary assessment, keratometry, ocular motility, pachymetry, biometry, and tonometry. In North America, the ophthalmic assistant also performs the automated or subjective refraction examination to determine best optical correction for the patient. The ophthalmic assistant does not write the prescription for the uncorrected refractive error to prescribe eyeglasses. This preliminary refraction is then typically followed up by the ophthalmologist who uses clinical judgment to determine the best prescription for the patient. Imaging has also become an important test performed by technicians. The technician performs diagnostic testing procedures including topography, specular microscopy, wavefront analysis, ultrasound (B-Scan and ultrasound biomicroscopy), optical coherence tomography (OCT) and OCT-angiography (OCT-A), and fundus imaging and fluorescein angiography.
The assistant’s role includes working with patients on preventive measures in dealing with eye problems, low vision with older patients, electronic medical records (EMR) and scribing for the ophthalmologist, rehabilitation of partially sighted adults, community volunteer work for vision and glaucoma screening programs, and international mission trips to serve the blind.
To ensure competency in ophthalmic assisting skills, IJCAHPO conducts certification examination on the core and specialty skills. There are currently 70,000 certified and noncertified ophthalmic assistants/technicians in North America. Canada and the U.S. ophthalmologists recognize these accredited certifications as milestones in the competencies and careers of allied ophthalmic personnel (AOP). Canada and the U.S. do not require licensing of ophthalmic allied personnel.
Two important studies by Astle et al. in Canada, and Woodworth et al. in the United States, showed that North American ophthalmologists highly value their certified ophthalmic assistants. Approximately 80% of these ophthalmologists indicated that certified ophthalmic assistants/technicians enhance practice productivity measures more than noncertified ophthalmic assistants ( Fig. 52.1 ). Astle et al. found that certified AOP contributed more than noncertified AOP in four measures: increased doctor productivity, increased number of patients seen per hour, improved trouble-shooting rapport, and improved triage screening.