Why do most doctors use “cash” accounting – Tips4EyeDocs Daily

One of the oddities of optometry practice is how practices count, record and allocate their income and expenses throughout their tax year.  Traditional accounting science revels in teaching first year students accrual accounting and yet most optometry practices use cash accounting.

The difference between the two is significant. Cash accounting recognizes income and expenses only when you receive it or pay it. Accrual accounting recognizes income and expenses as soon as it has become a promise or have an obligation. It is recorded on your books even though it hasn’t arrived at your bank. Likewise, you can record expenses even though you haven’t been paid out.

For optometrists, it is appealing to use cash accounting mainly for tax purposes. Since income and expenses are only recorded when actually received or expensed, the tax consequences may be affected by late year decisions. For instance, a doctor  may be able to report less income, simply by accepting payment from a patient until the next tax year. Likewise,  doctor may pre-pay an expense even though none had been presented by a vendor.  In accrual accounting this is not possible.

As one can imagine, cash accounting can disguise the current assets and liabilities and cash flow of a business. Cash accounting is accepted and there it is an absolutely bona fide manner to operate a business. However, it may disguise the “true” picture of the financial status of a practice, because it makes comparing businesses difficult in buying or selling a practice.

Accrual accounting, however, is the hallmark of most larger businesses and more accurately reflects the liabilities of a organization than cash accounting. Many more business benchmarks are available for businesses using accrual than for cash accounting.

In summary, the tax planning frequently dictates more of the kind of accounting than anything else.  Being aware of the kind of accounting being used makes the outsider much more inquisitive of the business owner as everything may not be as it seems.

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Spotlight on Gerald Eisenstatt, OD, MBA – Why an MBA?


Today’s Spotlight installment proceeds my post on the value of a postgraduate degree for optometrists (click here) For Dr. Gerald Eisenstatt, a 1984 graduate of the Southern College of Optometry, his recent MBA has placed him in the unique position of enhancing his directorship of the Hayes Center for Practice Excellence and his assistant professor duties at the Southern College of Optometry (SCO), his alma mater. Dr. Eisenstatt received his MBA from Christian Brothers University in 2011.  Dr. Eisenstatt is  also the managing partner of the Memphis Family Vision Practice, a multi doctor / multi location private practice.

Q1:  What prompted you to pursue the postgraduate degree that you selected?

I had a couple of reasons I wanted to pursue a postgraduate business degree. First, I wanted to improve my business knowledge so that I may provide a better quality educational experience for the students. I had 28 years of practical experience, but needed the business vocabulary and knowledge. Secondly, since I was the managing partner of my private practice, I needed to improve my business skills in an attempt to improve my bottom line. Profit margins were being squeezed by managed care plans and the overall cost of doing business.

Q2: If someone asked you which degree to pursue, what would you say?

I would strongly suggest an advanced business degree. Most optometrists are not properly educated in the basic business skills needed to become a  successful business person. Learning how to prepare a budget, develop a business plan and marketing plan, building a SWOT analysis and understanding basic accounting and finance all can be very helpful in taking your practice to the next level. Most optometrists fly by the seat of their pants and practice without much business guidance.

Q3: What or how has your degree benefited you?

Earning my MBA degree has been a win-win. I have started to better manage my practice and improve our bottom line. I was offered a promotion at the college which took advantage of my MBA and knowledge obtain during my higher level education. The students in my practice management class are now receiving a more comprehensive optometry business curriculum.

5. Summary

A postgraduate degree can precede or proceed your optometry doctorate. Either way, it can further enhance your career or business options in later life that you might not be apparent to you  presently.  As your career matures, there will be a moment when you know why, what and when you will want to pursue that postgraduate degree.

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Mutlifocal Contacts – Attaining Success Part 4 – Tips4EyeDocs Daily

It would seem that optometrists across the country have tried to or have achieved success in fitting multifocal contact lenses. Doctors want to do better. Because professional consultants and speakers that are funded or sponsored by the manufacturers cannot deviate too far from the “party line”, there may be a significant opportunity lost when success is achieved outside those boundaries. It is my goal to speak about these successes that don’t conform to what the fitting guide says.

One such example is fitting a biocular patient (a patient who has vision in both eyes but do not have binocular vision). Although not a common presentation, the methodology is similar to a normally functioning patient.  In this particular case, the patient had corneal pathology that reduced.
vision to 20/40 in the dominant eye many years before and 20/20 in the non-dominant eye.  For the past ten years, she no longer experienced diplopia. This was supported by 3rd degree fusion on the red lens and Worth Dot tests.

It may seem that the non dominant better vision eye should be fitted and the dominant poorer vision left uncorrected.  In this case, I prcoeeded to fit +2.00 Add multifocal lenses in both eyes with +0.75 distance overplus in the dominant (poorer vision) right eye and  a “on-sphere” Rx non dominant (better vision) eye.

The result was a lack of satisfaction  in distance vision with both eyes open. Taking the left lens out  and leaving the right lens in, however, improved significantly the overall satisfaction.  Note that I had not asked the patient to read an acuity chart.  Until I perceived that the patient was generally satisfied with the vision, I now hold off taking an acuity .  Also, I did not take individual eye acuities but just took vision at distance and near open together even though the patient was biocular.

What doctors, new or old, will find refreshing is that patient problems are not usually predictable.  Preconceiving a solution without adequately understanding the patient’s specific needs or constraints will not create a happy patient.  Our common goal, after all, is to create happy patients.

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Nostalgic for the optometry of “yesteryear”? – Tips4EyeDocs Weekend Edition

When eye doctors get togehter, either at a meeting or at a dinner, nostalgic thoughts occasionally captivate the participates to remember what optometry was. Some may even call it optometry’s “golden era”.  Today’s current optometrist may not appreciate that time period.

I talked with several 40+ year practitioners about that era.  Back then, optometrists were careful about the outward appearance of their offices.  Many sought a professional appearance by locating their offices in non-retail settings.  Some dreamed of going beyond what was then standard by actively seeking state legislation to use diagnostic drugs to examine the eyes.  But the majority of optometrists focused on “vision analysis”.

Examination fees were set mainly to accommodate a vision analysis and it seemed enough to cover the cost of the basic lane equipment . There weren’t retinal cameras or scanners. Some had isual field bowl tester rather than the felt tangent screen.  Some had non contact tonometers. But total equipment costs were modest then and it seemed that net margins of  vision analyses and ophthalmic goods were sufficient to allow for a comfortable lifestyle.

The competitive environment was much less then.  Most were independent private practices that just “hung their shingle out”.  Even if there were more than one optometrists within a single block, doctors still expected to see their practices busy within the second or third year.  Advertisement or discounting seemed unnecessary as patients were loyal and remained with the same doctor for many years.

The optometry itself was uncomplicated. With mainly the vision analysis as the centerpiece of a doctor’s visit, it was simple to just detect a pathology and refer. There was no expectation of managing it.  As long as the ophthalmologist did not have an optical shop, the optometrist would eventually see the patient back again.

Most optometrists welcomed new optometrists to the area because they belonged to the county and the state societies. Each doctor knew that whatever another doctor said or did, the “tribe” (of optometrists)  did not fear much because each trusted the other that they would uphold the common ideals of all optometrists.

Managed care did not seem prominent.  New graduates could depend upon managed care patients to give a boost at the start and whenever the patient  returned with or without vision benefits, the patient eventually returned to them.

Alas, this kind of optometry seems anachronistic. It has been superseded by a host of issues that seems to rent the profession into fragmented pieces.  Even the common goal of “optometry first above all else” seemed hollow today. The distrust is so palpable that it seems to be irretrievable.  I always wondered whether this issue or that issue really meant much to but a small fraction of the overall optometrists and how it seems to become the battle cry for the many more.

As any child that matures into adulthood, it seems that optometry has also matured to an organization that has to handle many more complex issues than ever before. The task for today’s optometrists is to retain “optometry first above all else”.

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5 Tips for the height-challenged doctor – Tips4EyeDocs Daily

Sometimes, it doesn’t seem fair.  It’s your first day at the office and some things don’t seem right. It may or may not be your permanent surroundings but you quickly note that the paper towel dispenser or rack is 6 feet off of the ground and the paper charts rack near the exam room door is similarly positioned.  Imagine reaching for the manual acuity chart projector and noticing it, too, is placed so high that you have to tip toe to reach it.

No it isn’t fair for the height-challenged doctor (HCD).  And you think that if you had to raise your hands above your head to do things day in and day out, you’re going to ache somewhere.   You just wished that someone in optometry school would have told you all of the hints and tips to get the working environment fitted to your needs and not someone who is 6’2″ tall.  Here are my 5 tips for the HCD.

  1. The paper chart holders – In offices where paper charts still persist, look to see where the chart holder is. If it is too high,  ask the staff if a small stool can be brought over and be positioned next to the door. It’s a lot easier than raising your hands above your shoulders to remove the charts.
  2. Manual acuity projector charts – If the office has them, and they are too high, I tend to show four lines of acuity letters from 20/40 to 20/20. This reduces significantly the number of times I have to adjust the slide mechanism.  Hopefully, an automated acuity chart that is remotely controlled would be available.
  3. The slit lamp and phoropter arms may also be set too high.  Note the height before your first patient because adjusting to it or commenting may take time away from the appointment.  If the office has a handheld slit lamp, this may be ideal especially if you can reseat the patient into a more traditional chair (a la reception room chair). This lowers the patient to a more comfortable level.
  4. Keyboards for computers may be on sliding trays or on stands with casters.  if they are too high (meaning the hands are above the elbow, then a small step stool may solve this.   Or find a terminal that is situated on a more traditional desk.
  5. Trial contact lenses are sometimes housed in customized cabinets or trays. Check this out before your first diagnostic contact lens fitting. If the most used parameters are above your eye level, locate a step stool or relocate the tray for better access.

In summary, being a HCD should not be a struggle. It takes a slight adjustment of the physical environment and most doctors’ offices are pleased to accommodate the preferences of any doctor. Therefore, don’t hesitate to ask for changes to the work environment if it doesn’t suit your needs.

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5 Useful Accessories for the Android Traveler

Whether by auto, plane or bicycle, the Android user of today can remain connected to the Internet, email and text messaging. Here are my five favorite accessories.

  1. AmazonBasics 2-Port USB Car Charger with 2.1 Amp Output (Black) http://amzn.to/zb3Tqb – What makes this an ideal accessory is its small size, dual ports and the feature of using your existing micro USB cables. I carry this to use on rental cars and is extremely dependable.
  2. iGo PS00273-0001 Charge Anywhere Universal Power Extender (Black) http://amzn.to/wyEXxg – This is a handy universal charger and power adapter.  On a DroidX2, it will charge a phone from 10% all the way up to a little over 80%. When not charging you can attach to a AC outlet and connect two smart phones using a microUSB cable. It is a bit larger than several packs of gum.
  3. Otterbox Defender Case http://amzn.to/A5IORd and screen – This combination really keeps my Droid X2 dry and clean. Because the Otterbox is a complete enclosure  onto the Droid, the I can clean the front screen repeatedly.  I then place the rubberized Otterbox over the screen and now I have a truly protective case.
  4. Sony MDREX36V/BLK EX Earbud Headphone (Black) http://amzn.to/wrgdJR – These head phones are light weight and inobtrusive. For the common carrier traveler, headphones shut out the outside world and retain the fidelity of the MP3 or video file you are using They are not noise cancelling but help pass the seemingly endless hours of waiting at airports or on a plane.
  5. Bluetooth hands free head sets – There are so many different manufacturers that any are invaluable for the traveler. In many states, it is mandated that drivers have to use a hands-free head set for their smart phones. It is also useful to listen to your phone messages with a hands free head set because it also frees your hand for note taking.

In summary, having a checklist for each trip will ease the anxiety of being in contact with your office or home as well as email.  All of these five accessories are “must-have” items. If you have your own list, feel free to post your comment on this blog.

Disclaimer: I have no affiliation with Amazon or any of the manufacturers or distributors of any product mentioned in this blog post.

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If I was a fill-in doctor – Tips4EyeDocs Daily 08Feb2012 – 47

If you are a fill in doctor, you might feel like a world traveler. Each morning, as you prepare for work, you might or might not know what city, what office, or even what room you might use or be in.  And like a frequent traveler, you might think about what you will need to pack for that office you will be in.

As a fill in doctor myself, I will bring some equipment. This is a partial list of that I would recommend for any fill in doctor.

  1. Tape measure – Cloth at least 3 feet and retractable. I like to measure reading distances and this demonstrates to the patient you asked about it.
  2. A favorite fundus lens – Frequently, the fundus lens available at the office might not be your favorite. I like the Super Vitreous Fundus Lens (134 degree view) by Volk. There are others that are equally capable. If you like the 90D lens, bring that.
  3. Reading cards – I like my Spanish language cards and because they are smaller than the traditional larger cards, they fit easily into my shirt or clinic coat breast pocket.  If I have to run from room to room, these cards are always with me.
  4. Retinoscopy rack – If I have to do retinoscopy or check the optics of a contact lens fit, these multiple lens racks are ideal.  I have used them to do spherical-best guess cylinder refractions in field optometry.
  5. Binocular Indirect Ophthalmoscope  (BIO) – Yes. often I will bring a BIO but I won’t unpack until I find out how usable the existing one is. My BIO has accessory lenses for near work and therefore, I won’t need to use the reading portion of my own glasses to see the virtual fundus image.  With this “BIO kit”, I will have my 20D lens
  6. A small flash LED flashlight. It’s great for muscle balance testing or just findings things in the dark.
  7. Copy of optometry license, certificates, etc. – I always have it just to ensure the office and the patients that I ‘m licensed in their state. I will also include a copy of my DEA certificate and my professional insurance policy.
  8. Fixation targets – I carry finger puppets with me and they are great for children or even adult patients to check on eye alignment and conjunctive eye movements.
  9. Sample independent contractor agreement if one is needed.

In summary, I like to be prepared when I enter another doctor’s office. In this way, I can blend into the workflow without disrupting their routine.  If you have suggestions for additions or deletions to this list, please feel free to comment on this blog.

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5 Android Applications for the Traveler – Tips4EyeDocs Daily – 07 Feb 2012 – No. 46

Air, train or car travel all present unique challenges to the connected Android user.  While the abilities of phones have dramatically improved over the last couple of years, the ability to stay connected while traveling still provide many challenges, especially for the traveler.

  1. Airline Ticketing, Reservation and Status – This is absolutely the first application that I use consistently.  Many, if not most of the major airlines have their own Android applications which are free. If you travel on the same air carrier, then it makes sense to use one of these. Because I travel on different carriers, I use on of the general travel applications. In this way, I can reserve flight, a rental car and a hotel quickly.  If I need to change a flight, I can quickly scan for alternatives.  Flight status applications are equally important.  Although I could download a paid Android Application for this, I find that the Dolphin browser can keep my forms data in memory and I need only to refresh the screen to check on flight status.
  2. There is nothing more helpful than a game or two to tide you over when you’re waiting in either the security, snack or gate area. Games are usually quick ways to keep you busy and alert when that public announcement calls for a gate change, a flight cancellation or boarding time.  I like the solitaire card games for this particular reason.
  3. If you know your wait will be an hour or more, then an entertainment application will help. The most functional for me is NetFlix.  It appears to have the lowest bandwidth constraint and has one of the best “remember-my-place” I have ever seen. If I’m interrupted for one reasonor another, I can quickly return to the exact place I left.  A constraint I have noticed, though, is that 3G/4G networks can get busy in an airport and thus throughput is a challenge.  Interestingly, if you’re a passenger in a taxi and get stuck in traffic, the NetFlix application will beautifully in most large cities.
  4. Map/navigation software has been very helpful for me while travelling by car, taxi or by foot. I just cannot remember the many times that this software has guided me safely and carefully to my destination on time. Both Google and your phone carrier will have their own versions of navigation software. I  have used one of the dedicated GPS devices and found them equally useful, although not necessarily the most practical if one is trying to minimize the number of devices being carried.
  5. When I’m in an unfamiliar location, I have also found one of the location applications very helpful.  These kind of application will use your GPS to locate or list points of interest, nearby coffee shops or fine or video arts that you can quickly and easily visit.

In summary, the astute Android phone user on business or personal travel will reduce their anxiety scientifically with special purpose applications. They wile away the time, keep you on course and keep you connected to the rest of the world.

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What is the price of compassion? Tips4EyeDocs Daily – 06 Feb 2012 – No. 45

We are all caring professionals. Our patients not only want clinical expertise but also compassion. It is unmistakable that is an integral part of a patient encounter. It is a key component to a successful outcome and to a successful practice. But compassion is difficult to define, master and inculcate.

To a patient,  compassion may take many forms. First, it can be seen by the patient as  “active” or “reflective” listening. This is a kind of listening that is not biased and conveys no judgement by the doctor.  To busy doctors, however, we may unknowingly signal indifference because we are accustomed to listening for a chief complaint or contemplating what battery of tests to order. We might even interrupt a patient is not responding directly to a question.

Second, being dismissive of a patient’s concerns or questions may look like indifference.  Although a doctor may not have all of the answers at hand whenever a question is asked, discouraging questions always leads to decreased compliance to treatment or management.  Patient questions are based upon real concerns and may be an attempt to “get-to-know-the-doctor-better”.  Or it may be an attempt by the patient to frame questions that are useful. Acknowledging at least that you understand they have a question will somewhat ally this concern.

Lastly, compassion includes how the doctor presents the case.  Doctors tend to fall into two categories. On the one hand, the doctor may prescribe and the patient is expected to follow. On the other hand, the doctor and patient can share in the decision on how to manage. On the whole, most doctors fall into the latter category, but we may always execute better each time.  Not discussing or sharing in the decision means that the patient’s input is discounted even though the doctor may not intend for that perception to occur. It still does.

In the natural and normal course of clinical care in optometry, no significant depth of compassion is often needed or even required. But I believe the more that we can practice or exhibit compassion, the better our outcomes might be. When a doctor can sense that deeper compassion is required, we should not await any further or additional prodding to practice it.

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What is the value of a postgraduate degree? – Tips4EyeDocs Weekend; 4-5 Feb 2012; No. 44

Postgraduate degrees after the optometry (or any professional) holds a special place of importance in career planning. Typically, only a minority of doctors will ever think of another degree.  In the face of changing social, economic and political changes, however, a second degree may enhance career opportunities outside of the traditional examination lane.

Because doctors mainly concentrate their lives in their offices or in other clinical positions immediately after graduation, there is little thought that a career away from the office is ever contemplated. And these years in the office may not be relevant to any other career opportunities. To qualify for these another career, a second degree, usually a master’s or even a another doctorate may compensate for some or even all of the requirements of that career move.

The most common second degree is a masters degree and the concentration may vary from business to public health to public administration and even to a humanities area. The career opportunity that an eye doctor seeks will usually dictate the kind of masters degree.     Most aficionados of pedigreed degrees tout the networking with other students while other more pragmatic devotees will cite the ability to continue one’s own career while seeking the masters degree.

The pedigree of a degree is also not so important because this is a second degree. That means the the degree from a full time or part time basis; on site or online; public or private will not necessarily impact the your worthiness as a candidate

A new form of postgraduate education, the certificate, is also an option worth considering. Often certificates are focused on a specialty and may be obtained in clinical affairs, clinical research management and quality control; all areas that are relevant to the second career optometrist.  These certificates are short and can be completed in as little as six months; far shorter than a masters degree.

I’ve taken the approach of obtaining both a graduate business and a public administration/policy graduate education. In the former, this allowed me to take a hiatus or sabbatical from active clinical care to work in three computer hardware and software companies; something that is in no way related to optometry.  In the latter, I have met many other governmental policy experts and have become acquainted with federal and state policy formulation and analysis in areas outside of optometry.

In summary, there is value to a second degree or certificate after your doctor of optometry degree. It may provide geographic mobility that is almost impossible with just an optometry degree. And often the clinical knowledge and experience combined with the second degree will make you a worthy candidate for any employer.

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