Introduction & Clinic Operation

Clinical Expectations – The BV clinic should be a pleasant place, where we all enjoy what we are doing and continue to learn. This applies as much to patients, parents, students as it does to instructors.
Therefore, we want to be straightforward about the goals for you this term.

• Goals and Objectives for the BV clinic =
  Teaching and Patient Care
• Goals and Objectives for the summer (first time BV third year curriculum) =
  General Intro and Acquiring Skills
• Goals and Objectives for second time BV, third year curriculum =
  Improving Skills and Expanding Knowledge
• Goals and Objectives for fourth year curriculum =
  Expanding and Solidifying Knowledge and Skills.

As always, it is important that you ask questions. If you are not sure, ask!

• BV patients are frequently complex. You are therefore expected to develop diagnosis and treatment in conjunction and conference with your attending faculty, not by yourself. Work with your instructors to ensure good patient care and learning.
• Questions promote learning! Our strongest students always ask and interact with faculty the most.
• PLEASE, do not “hide” in your exam room or wait until the last 15 minutes of the exam to ask for help.

How BV is different from Primary Care:

We are providing tertiary care as well as primary care, within a private practice concept.

• Concept of primary care; triage and entrance into the system
• Concept of tertiary care; referral from colleagues and other professionals
  • Neuro-optometry and children’s vision in the binocular vision clinic
  • Strabismus (comitant and incomitant) and diplopia
  • Amblyopia
  • Orthoptics and training of symptomatic phorias
  • Head injury and stroke patients
  • Learning difficulties
  • “Tracking difficulties”
• Concept of private practice:
  Each patient is registered with a “Doctor in charge“. Your can identify the doctor in charge by the colored name label on the chart jacket. Make sure that you check in with this particular instructor, at least once before they leave the clinic for the day. Other instructors will also help.
• Patient Columns and working as partners
  • Keep your own patients in your column for follow up. DO NOT SWITCH COLUMNS. We are not using the “first come first served” method in our clinic.
  • In the case of a planned absence, your partner needs to cover the column. Additionally, only 30% of the clinicians in a module may be absent per clinic day, per Dr. Revelli.
  • If you are having any difficulties working with your partner (or in a partnership), please come to your instructors early in the term to resolve the issues. There are many ways that the situation can be solved without embarrassment for any of the people involved.
• BV evaluations #1 & #2 = 90 minutes each, $278.00 total fee
• BV exam = one 90 minute exam for $87.00. These patients have usually been seen in the BV clinic before and are coming back for yearly exams and check-ups of specific areas that were weak before.
• BV-follow up appointments (i.e. amblyopia or Rx follow up) = 45 minutes. Please note that sometimes follow up appointments may be longer depending on need. Follow up appointments are $80.00 per appointment.
• Vision therapy is scheduled in blocks of eight- 45-minute sessions for $810.00 total. This fee includes the therapy kit used for the entire therapy program.
• Abbreviated Perceptual Skills Assessments (PSA) with Report and Informal Reading Inventories (IRI) = 90 minutes per appointment. These evaluations are scheduled over three x 90 minutes. The total fee is $470.00. A short report is included in the fee.
• Complete Perceptual Skills Assessments are scheduled over 5 visits (including the parent conference) PSA = $630.00, which also includes a short report.
• Charting during the Binocular Vision Evaluation: Please use the BINOCULAR VISION EVALUATION form and leave the right column on the form for instructor comments, when appropriate. Use the same form for both BV#1 and #2. The instructor in charge of the patient needs to sign the form and preferable individual side notes, if they are different from the findings noted by students.
• You are required to fill out the patient’s fee form with the appropriate BV service code and corresponding fee. Please also write in your student number, the instructor’s name and the Mod (i.e. BV) on the top of the form. Instructor signature of the completed form is REQUIRED before fees will be processed at the cashier. This needs to be the signature of the instructor who manages the case. You are encouraged to interrupt the instructor for a signature, when at all reasonable to do so.
• No double booking should be done without discussion with instructors. Teams of 2 clinicians in most columns. If you are a team of three clinicians, work with your instructor to ensure that you get adequate patient exposure and can book a few extra patients.
• Practices within a clinic (ie;B11,S31,H41). B12 = Dr. Boe, Monday, second column of patients
• Our clinic provides modified “DPC”= Direct Patient Care. Our care and fee structure reflects that philosophy. Your Instructors are ultimately in charge of the patient, but students are responsible for their patients’ daily care. Please refer to name labels on the chart. The faculty who is present at the “intake” will usually be the doctor in charge.
• Faculty Credentialing:
  • Credentialed faculty: Drs. MarkWu, Jennifer Lim, Karen Chester, and Debora Lee
  • Review cases before and after the patient encounter. The managing doctor finally signs the daily report.

General preparation for BV clinic:

• Positive attitude Basic skills
• Equipment-make sure you and/or your partner bring the items mentioned below each week
• Handouts and lecture material; we recommend that you keep your material a binder.
• Bring your VT/PSA manual or borrow one from a classmate, if you do not have one.
• Pediatric Kit (small toys and little books for “in-between” entertainment; good for primary care).
• Please keep our in-house Pediatric Kit intact. Feel free to use our small in-house children’s library for your activities. These are precious resources, which sometimes are hard to come by.
• Positive attitude

Seminar and Case Review

• Each team is to give a succinct case presentation for each patient in that team’s column at seminar
  

  Age (year and months)	Expected Grade Level	Any Previous Dx and Tx including the Duane’s classification
  Gender	Chief Complaint & POV	Plan for the Day

• To prepare for your case presentations, you are strongly encouraged to do the following before seminar:
  • Review your charts. If this is completed before the seminar, your presentation will be more efficient and you will be better able to listen and learn from your colleagues’ presentations. You will find the hand-out “Chart review” to be helpful during preparation of patient encounters and reduce stress!
  • Assemble the necessary forms and paperwork.
  • Gather and organize all vision training equipment to be used for in-house training.
  • Develop a plan for each patient and record the plan on the appropriate exam form
• Seminars: During the Summer semester, third year AM students begin seminar at 8:00 am, PM students begin at 1:00pm and all fourth-year students begin seminar at 8:30 am. If you are not prompt, we will start seminar without you.
• Clinic Schedules:
  Third Year AM Summer Students: Clinic hours are from 8:00 am to 2:30 pm.
  Third Year PM Summer Students: Clinic hours are from 12:00 pm to 6:30 pm.
  “Free time” is best used for preparation time and letter/report writing.
  (Third Year Fall/Spring Students: Clinic hours are from 10:30 am to 6:30 pm.)All Fourth Year Students: Clinic hours are from 8:30 am to 6:00 pm.
• Please note that there is no time to prepare between seminar and patient appointments. Therefore, we recommend that you set up your exam rooms before seminar starts and pull all necessary equipment and tests. Have your VT equipment set up and your PSA tests set up.
• Security: When you leave your exam room, close the door; and when you leave the clinic, lock the door. DO NOT leave valuable personal items unattended. Over the years, students have lost their entire diagnostic kits, because they left rooms open and unattended.

Attitude/work ethic

• We value students who know their limitations and we reward students who are proactive and interactive learners. There truly are no “stupid” questions.
• A note on using the computer: checking your personal e-mail is restricted to clinical use only (i.e. letters, communications with instructors) and internet access is for optometry, medical and/or educational websites only. You have extended special internet privileges. If abused, WE will loose them as a group.

Grading

• To successfully pass the course, we expect you to have fulfilled the objectives for your session. Your daily and semester performances will be assessed in the following categories: Interpersonal Skills, Clinical Techniques and Skills, and Clinical Thinking and Analysis.
  • Basic/primary care skills must be satisfactory for third years by the end of summer session. For returning third years and fourth years, these skills are expected to already be fine-tuned.
  • BV skills(BV evaluation and BV exams), Vision Therapy and Perceptual Skills (PSA and training)
    • Summer session third years need to be able to do a basic BV evaluation, run a VT program for minimal binocular vision dysfunction, assist in the administration of a PSA, and complete a PSA letter by the end of the session.
    • Second entry third years are expected to manage the VT for amblyopia and intermittent deviations. They should also have been participating in the analysis and management of either visual perceptual or reading disabilities.
    • Fourth years should be able to do the above early in the session and are expected to grow in order to handle more complex cases. At the end of the session, our fourth years are expected to be proficient in examining incommitant deviations, amblyopia and intermittent strabismus cases.
    • Midterm goal for our fall and spring third years: In addition to patient care, the second entry third year students are expected to complete a small goal of choice. This goal needs to involve some basic presentation such as a handout or small presentation. It could also involve further development of some of our clinical material for testing or training.
    • Midterm goals for our fourth years: Our fourth year students are expected to complete a small project on a subject of their choice. The presentation should demonstrate improved knowledge of the subject; listing of researched references and be presented in a professional manner.
  • Participation in seminar is regarded as an essential skill during your clinical experience.
  • Prompt on paperwork: all letters completed to instructor’s satisfaction by the last day of the term. In addition, the quality of your letters is considered in the grading process.
  • Follow up on patients. This involves as much paperwork and the ability to follow your particular patients care for referrals and visits in other clinics.
  • Be ready to present your third year midterm goals at midterm evaluation or earlier
  • Third year midterm goals completed one week priorto final evaluations!
    • Third years
      • New to BV: You are expected to show proficiency in those tasks and exam techniques listed on the handout for “the proficiency exam”, and to be able to perform those tests in a patient situation.
      • Returning to BV: your goals will be mutually decided on during your midterm evaluations. Goals may be remedial in nature if necessary. Otherwise, they should be based on your areas of interest in BV. Please put some thought into what you would like to accomplish through your goals before your midterm evaluation.
    • Fourth years: your goals will be mutually decided upon at the beginning of the semester. It is expected to be completed at the date selected by the student. Please put some thought into areas that you might need or want to work on before your evaluation.
• Ranking with all classmates
  The clinical director’s office requests a ranking of all students completing the BV rotation. Currently, clinicians have elected to have this information eliminated from the evaluation form and the informal feed-back sessions at midterm and finals. However, the information is available and will be released upon individual student request.
• Letter grades
  At midterm, information and feed back is provided to each student. The result of the assessment of each student’s performance is documented on the student evaluation form. Only a pass or fail is issued at that time. Please see sample of form (submitted as an attachment). Should a student be identified with weak clinical skills, The BV faculty make every effort to identify, intervene and remedy a students clinical knowledge early in the course.
  An update of the student’s performance takes place at finals. At that time, a final grade is issued. The grading strictly follows the official grading of optometry students under the graduate division system.

Check-ins with the instructor. Please remember that our clinic is a modified DPC clinic.

• Your instructor should be present at the “intake” (initial case history) of all BV Evaluations and new patients.
• No patient leaves without doctor interaction/summary at the end of the visit.
• Check in before drops
• Check in before reviewing home VT with the patient and parents
• If at any time you or your partner are unsure of what to do, please save time by checking in and ASKING

Computer summary print out

• When prompted to choose an exam form, select BVEX_UCB for entering your exam data and for printing select ABV_EXAM. This will give you a second screen for “Additional Notes.”
• List the type of Exam under Fee level
• In the “Diagnoses” box
• Dx (ICD codes) in this order
  • Duane’s classification: For example, basic exophoria, convergence weakness, or divergence excess.
  • Accommodation and/or Vergence system
  • Ocular Motility (saccades, pursuits)
  • Pathology
  • Refractive error – please do not list this first
  • Additional data such as TAAS (phonemic awareness), TVAS (spatial planning), or DEM (Rapid Automatic Naming/spatial planning/ocular motility) results may be included if room permits
• In the “Plan” section (which may need to be continued on “Additional Notes”):
  • Impression of results. Please group into systems. For example: Normal ocular motility, presence of sensory & motor fusion found on the amblyoscope, reduced accommodative facility, moderate amblyopia with crowding on linear acuity. Average performance on all perceptual screeners.
  • Treatment plan to include advice given and all tests to be performed at next visit. Please be specific! For example, if beginning vision therapy, list 5 VT exercises for in-house and 3 home exercises. The exercises need to be specific as follows: 2 bead Brock string with 1st bead at 1 foot and 2nd bead at 3 feet. If scheduling a follow-up visit, state tests to be completed as follows: distance and near linear visual acuity, pediatric worth light, Frisby stereo, visuoscopy, monocular contrast sensitivity.

Necessary Equipment: You need to borrow from colleagues, if the equipments are not in your case

You need to able to assess binocular vision skills in free space rather than in the phoropter!

Letters

• All referrals into our clinic require short letters thanking the referring optometrist and summarizing what we found and what we recommend for treatment. We also write letters for all PSA’s.
  • Format: Use templates under the “Tree” icon on the computer for every letter, unless told otherwise. If you are unsure of which template to use, ASK FIRST.
  • Open the template and perform a SAVE AS first. DO NOT write over the template.
  • Save letters under the “Tree” icon in the appropriate folder in Alphabetical BV Letters.
  • Patient’s last name, patient’s first name, type of letter, and instructor’s name
  • Example: Doe, Jane-BV Eval [Scheer] or Smith, John-PSA [Boe]
• BV Evaluation Summary
  • By the end of the BV eval #2, you should have completed the “plug in” version of the BV evaluation letter. Please check with your instructor if he/she would like to review the letter on the computer or as a printed version.
  • BV summary corrections and final due 2 weeks after completion of evaluation.
  • Template is the following:
    G:\BV\Letter Templates\BV eval plug in ALL DOCTORS
• Perceptual Skills Assessment report
  • Body of the report in good working condition due by the conference (also summary visual skills report to be completed if not in the computerized version-ask if unsure)
  • Fill out the “Pyramid” together with your partner and faculty
    • Please check for correct pronouns, names, and correct commentary/data.
    • If you are unsure if a statement in the template applies to your patient, highlight the information in question; don’t leave false information
  • Corrections and final draft due 2 weeks after conference
  • Abbreviated report template is the following:
    G:\BV\Letter Templates\Abbreviated PSA Report Samples\Abbreviated psa letter new version.doc
• Emails: These are our personal emails, DO NOT release to patients and parents.
  

  Dr. Hoenig: pia@sonic.net
  Dr. Boe: brettnkt@brettnkt.com
  Dr. Scheer: yolandascheer@yahoo.com
  Dr. Kuntz: shawnakuntz@yahoo.com
  Dr. Worrall: rsworrall@foothill.net
  Dr. Belanger belanger2020@gmail.com

  Dr. Hoenig’s official clinic email: phoenig@optometry.berkeley.edu

Clinic Manual