Category: Patient Care

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WHAT IS A PATIENT?

Different types of patients in reception area

Reading time 3:34

WHAT IS A PATIENT?

“A patient is the most important person in the institution- in person or by mail.

A patient is not dependent on us- we are dependent on them.

A patient is not an interruption of our work- it is the purpose of it.

The patient is not an outsider to our business- they are our business.

The patient is not someone to argue or match wits with.

The patient is a person and not a statistic.

It is our job to satisfy them.”

William E. Lower, M.D.

The Cleveland Clinic Foundation

February 1921

WHY OUR PRACTICES EXIST

I first became aware of this quotation in 1975 when I began working at the Cleveland Clinic Department of Ophthalmology.  Dr. Lower was one of the four founders of the Cleveland Clinic. This was part of his speech at the dedication of a new building in 1921.

In recent years, I realized the similarity to a quotation attributed to  Mahatma Gandhi in 1890.  I suspect that the Dr. Lower quote was a paraphrased version of the Gandhi quote. For your reference, I have also included the original quotation at the end of this blog. Both quotes eloquently express the reason for a patient or consumer based business to exist in the first place. To be successful, we must serve the public and satisfy their needs, for without them our practices would cease to exist.

Most importantly, what was true in 1890 and 1921, is still true today.  It is something we should never forget. 

AN AVERAGE DAY

It is so easy to get caught up, or bogged down, in the day to day running of our practices.  We wish for those early days when all we had to do was see patients.  For example, now we also hire, train and supervise our staff, handle insurance claims and endless paperwork, and negotiate with vendors. Meanwhile we also need to plan for the future and deal with anything else that might come up in the course of a normal day.

GETTING BACK TO THE BASICS

Sometimes, it’s just important to get back to the basics.  Stop for a moment and remember why we chose optometry as a career and what we want to achieve.

Reflecting on our underlying goals doesn’t make all our problems and concerns go away.  But, it does put them into perspective and gives us a chance to clear our minds.  It’s an opportunity to just reboot ourselves. In other words, we can dedicate ourselves again to creating an office that truly serves the patients and answers their concerns. But, we can also create an office that is a source of pride and satisfaction for the doctor and the staff.

We need to recognize the importance of the doctor and staff in this equation. If there are ways to decrease stress and tension in the office, then that should become a priority as well.  If we aren’t personally happy, we can’t serve others to the best of our abilities.

MAKE IT A TEAM EFFORT

Include your staff in identifying problem areas and trouble-shooting solutions. Their inclusion sends a message that everyone is a valuable member of the team.  Each person is then invested in the success of the practice. Remember this is an on-going project.  It does not happen overnight.

Meanwhile consider sharing this quote with your staff as a reminder of the reason we all come to work each day. It can also be a challenge for what you want to achieve.  It could be displayed in a patient care area as well. It makes a clear statement to your patients.   It shows your commitment to quality and personalized eye care. In other words, it stresses how important your patients are to you.  Sometimes that message gets lost for the people who need to know it the most.

A FRESH START

Taking the time to find our original motivations can reinvigorate us. Certainly, it can also inspire us to reinvent ourselves and become even better at what we do. Taking care of our patients becomes the most important part of our day. To paraphrase- our patients are “…the purpose of our work.”  When our patients know how much we value them, it helps to distinguish ourselves from other practices.  By making sure patients know and feel how much we care, we can only hope that they will continue to give us “…the opportunity to do so.” 

Everything becomes easier when we concentrate on the “why” we chose to practice optometry.  It might even bring back some of that idealism and enthusiasm that seemed in endless supply when we graduated and started to practice.

For your reference, here is the original quote from Mahatma Gandhi.

“A customer is the most important visitor on our premises.  He is not dependent on us.  We are dependent on him.  He is not an interruption of our work.  He is the purpose of it.  He is not an outsider in our business.  He is part of it.  We are not doing him a favor by serving him.  He is doing us a favor by giving us the opportunity to do so.”

Have you ever surveyed your patients to see where your practice is succeeding and where they think you can improve?  How do you keep yourself charged up and enthused about what you’re doing?  Share your ideas with us.  In the comments below, let us know what has worked for you in your office.

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EQUIPMENT MAINTENANCE IN AN OPTOMETRY OFFICE

Picture of a refractor

Reading time 4:29

Any optometric office has certain basic pieces of equipment that allow us to provide vision care. If these instruments are not in proper working order, then it becomes difficult to do our job.  Therefore, the maintenance of our instruments should be of the utmost importance.   

“THE GOOD, THE BAD AND THE UGLY”

After graduation, I worked in a large clinical practice for twelve years. Then for nineteen years, I was in a two doctor partnership. But, in the twelve years since then, I have actually worked in many different settings.  This allows me to have a unique perspective on how different offices operate.

Every practice I have worked in has incorporated new technology at different rates. This is influenced by the priorities of the doctor/owner and the needs of the patients that practice serves.  Those decisions must be made by the doctors and I’m not here to advise, criticize or judge anyone on their choices.  However, I do have some observations to make on the state of repair, or disrepair, in some offices.

HERE’S TO THE GOOD

 I was lucky because my first job out of school was in the Cleveland Clinic Department of Ophthalmology. This was in 1975. There were twelve ophthalmologists on staff.  I was the first and only optometrist on staff.  At that time, there were very few optometrists and ophthalmologists working together. 

We had a residency training program that had twelve residents and also several fellows in different specialties.  As a result, we had a full complement of technicians, receptionists and all the other people necessary to run the department.  

In a department of this size, it stands to reason that we had a lot of examination rooms and even more equipment.  We had the best and most advanced technology available. Our equipment was well-maintained and checked on a routine basis.  

The leadership of the department had the wisdom to keep all our equipment in good working order.  Any time something was out of alignment or not working properly, it was placed on a list.  We had an excellent repair person who came in once a week and took care of everything on our list. After that, if there was time left over, he would start to do routine maintenance and calibration on all the equipment room by room.  In this way, every piece of equipment received routine care, calibration and maintenance.  I realize that this level of maintenance is the exception rather than the rule.

It’s not possible or practical to have someone on retainer for a regular sized office.  But, the lesson I learned about equipment maintenance has stayed with me throughout my career.  We are an equipment dependent profession.  We must not neglect its maintenance.  And yet, what I have seen in many offices has surprised me. 

AND NOW THE REALITY

When I do work for other doctors, I never know what I will encounter. Keep in mind, I don’t object to using old equipment. I’ve used old Greens refractors. Those refractors were built like tanks and I doubt they will ever wear out.  Old non-contact tonometers can be a challenge as well.  But, the point is that it’s not the age of the equipment that bothers me- it’s the state of repair. 

THE COSTS OF EQUIPMENT MALFUNCTIONS 

The sad state of repairs I have seen in some offices both amazes and frustrates me.  I know we all get good at jerry rigging equipment to make it through the day. I’ve been guilty of this too.  We all learn some basic repairs so we don’t have to shut down the office when something breaks.  But, working with equipment that is not functioning well is annoying and inefficient. 

When you have to fix equipment or move patients to a different room it reflects badly on you.  It makes you look cheap and/or inefficient. That’s not the way you want your patient to remember your office.  

DOES ANY OF THIS LOOK FAMILIAR?

Some problems I’ve encountered are: 

  • Binocular indirect ophthalmoscopes (BIO) that have shorts in the cords and flicker off and on.
  • Project-o-chart slide with a shadow over half the screen.
  • Slit lamp tables that don’t move easily or won’t stay in place and have to be held in the proper position. 
  • Phoropters that won’t lock in position.  When the patient leans against it, it moves.   
  • Stereopsis books that are unglued and falling apart and the glasses are missing a lens.  

True, these are minor problems, but they still look bad.  In the next room there may be a fundus camera, an OCT or an automated perimeter. These new technologies could impress your patient, but not if basic instruments are falling apart in your exam room. 

The patient may not say anything to you, but don’t believe for a second that they don’t notice.  What would you think if you went to a doctor who had instruments not working properly?  Patients do notice and believe me, it doesn’t leave a good impression.

SUGGESTIONS FOR AN EFFICIENT OFFICE

We are all anxious to have the newest technology in our offices. It improves the care we offer to our patients.  But, we can’t ignore the stable utilitarian tools we have used for years or let them fall into disrepair. They have saved me on more than one occasion.

Everyone needs to establish a good relationship with a company that provides equipment maintenance and repair.  Then when you do need a repair done, you know who to call and know they will respond. Previous experiences with them means you know they are reputable and the job will be done well and promptly.

Make a checklist of all your equipment and the recommended intervals for maintenance.  Have someone train you, or your staff, in some of the basic repairs.  For example: eliminating shadows on manual projectors, calibrating your instruments and doing some basic cleaning and maintenance are all simple.  Learn to write down whenever something needs a repair and then when you do have to call someone in, you can have everything  repaired at once.  Having a list means you don’t have to rely on your memory when a repair person is called. You can tell them all repairs that need to be done at once. 

MAKE A GOOD IMPRESSION

Do you have back-up equipment to allow you to continue to see patients if something goes wrong?  Do you have back-ups for bulbs, fuses, paper or anything else required for the proper functioning of all instruments? Make your life easier and your day go smoothly. Be prepared.

Look at your office through your patient’s eyes.  They notice the little details more than you think they do.  

How do you handle routine equipment maintenance in your office? Does your staff know how to troubleshoot minor repairs?  Is there a plan in place if a major malfunction occurs?  Let us know what you do in your office by writing in the comments below. 

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TAKE A LOOK AT READY-MADE READERS

Reading time 5:09

ALWAYS SOMETHING NEW TO LEARN

During my first year on staff at the Cleveland Clinic, I learned a valuable lesson from a first year resident in ophthalmology. I was responsible for teaching the residents the basics of primary eye care. That included optics, refraction, contact lenses, low vision, and anything else that came up.

 I was fresh out of school and ready to tackle the world.  Little did I know how much more I had to learn. 

One of the residents was asking me about ready-made readers and what I tell my patients about them.  I considered for a moment and then said I would say that custom glasses are better for you.  

The resident had an interesting addition to my response that I had not considered before.  She said that she first reassures patients that ready-made readers won’t hurt their eyes, but then points out that custom made pairs are better.  It’s a small distinction, but an important one. Keep in mind this was in the 1970’s long before transparency became such a priority in communication.  As it turns out, trust and honesty have always been important to building a practice.

Her argument was if you try and convince people that ready-mades will harm their eyes- it’s a losing proposition in many ways. For example- you have just completed a full exam and pronounced their eyes healthy except for presbyopia.  Then the patient asks you about the ready-made pairs.  Let’s say your response was negative and you told the patient how much harm ready- made readers can cause their eyes. 

But let’s take the story further.  What if that patient has actually been using readers for years and just doesn’t tell you about them.  You just pronounced their eyes healthy. And in the same breath, stated they will harm their eyes with ready-made readers.

You have just lost this patient’s trust and respect.   You now look like a liar and an opportunist trying to sell them expensive glasses.  Once you lose a patient’s trust on something so basic, it’s hard to ever get it back.

DEVELOPING PATIENT TRUST

The resident’s response made so much sense to me that it changed the way I speak to my patients.   I want my patients to always trust me and know that I will always be honest with them. I want my patients to come to me for advice about their eyes and not go somewhere else. This conversation took place in 1978 long before Google, the internet and social media.  This was a time when patients were not playing as active a role in their care as they are today. I think honest communication is even more important now.

Now when I am asked about readers, I confess that I actually have several pairs laying around my house. I use them for emergencies if I don’t have my progressives on. 

I do tell my patients that ready-made readers won’t hurt their eyes. But I point out the reason they are cheaper is the quality of the lenses and frames are not as good as what we use in custom eyewear.   I explain that readers may have increased aberrations and distortions that can result in headaches and eye strain.   

I also point out that ready-mades assume that a person’s correction is the same in each eye and that the patient has no astigmatism. Then I honestly share if I think their prescription might create any problems for them in using ready-made readers. I offer my opinion on whether they will work for them. But, I never say or imply that they will harm themselves.  

Most people treat ready-made readers as disposables and have multiple pairs.  Almost everyone knows someone who uses ready-mades. And most people who use readers will also admit they have some pairs that give them a headache or eyestrain.  This supports the information I give my patients about the decreased optical quality of these lenses.  

AN OPPORTUNITY TO EDUCATE

The public has a basic distrust of us because of the high cost of premium optical products.  They look at the ads and wonder how the cost of glasses can be so different from one office to another.  I believe patients want to understand why there are such discrepancies. If you don’t use this opportunity to educate them, their natural conclusion is that the doctor is making a huge profit. 

This is where transparency can be helpful.  The less explanation you offer, the more they will assume the worst.  I know that others may disagree about discussing the cost of these glasses.  But I feel my willingness to discuss the wide range in pricing helps patients understand the differences and builds their trust in me as their doctor.  

I often use the analogy that there are different qualities of TVs, computers, and cars.  People understand that. They know that there is a difference in the quality and reliability of a reputable product versus a cheaper one.   We have all learned this through painful and expensive lessons.  We know we get what we pay for.  

This discussion also allows you to offer the importance of proper frame selection, optical measurements and adjustments of a frame to best serve each patient.  And that can lead into information on warranties and how your practice stands behind any glasses you dispense.

RESPECT YOUR PATIENTS

When you’re honest, you keep your patients’ trust. You don’t look like you’re just trying to make money off an unnecessary expense. Realize that patients may not have the money for new glasses now.  Presenting them with options in an honest and open way allows them to make choices and understand the differences. Demonstrating the difference in the readers vs. their custom made set shows your willingness to help them make the right decision.  Often they will notice the difference themselves and make the right choice. You can also offer them other options such as multifocals, computer glasses and contacts.

CONTACT LENS WEARERS AND READY-MADES

Something else to consider. What advice do you give contact lens wearers who are beginning to notice presbyopia? They may be just having a little intermittent trouble at near.  They’re not ready yet or don’t want to be refit in mono-vision or a multifocal contact.  Don’t you tell them to pick up a pair of ready-made readers? 

Don’t be a hypocrite. What do you imagine your patient will think when they know that you told their relative or friend to not wear any ready-made glasses?  Now, for the contact lens wearer, you’re telling them to go get a pair. Honesty and consistency are always the best.

MAKING A DECISION

In my practice, we always had some readers on hand to use with people in our office.  Patients could use them to fill out forms if they forgot their glasses. Ready-mades were also useful if a patient needed to read something while they were dilating.  We would even loan them out if our patient had to return to work. We wouldn’t charge the patient anything if they returned the glasses in good condition.   If the readers weren’t returned, the patient was then charged for them. Our patients appreciated this and did not abuse this benefit.

We also offered ready-made readers for sale. I got tired of seeing so many patients using readers and buying them outside my office.  Since people look at them as disposable anyway, there is not a lot of adjusting or repair required if you decide to inventory them.   You can also offer better readers or ones with anti-reflection coatings.

It has always bothered me when someone else makes a profit off of readers when I am the most qualified person to see to my patient’s visual needs. Though I don’t have the data to prove it, I really don’t think we lost many sales of custom eyewear by having ready-made readers available.  If a patient wants ready-mades, they will just go somewhere else and find them if they’re not available in your office.

I know that my ideas may be controversial or unacceptable to some. Everyone has to decide what works best for them. But, I do hope that this blog at least makes you think about what, and how, you answer your patients’ questions.

How do you handle questions like this in your practice?  Do you place yourself in your patients’ position and try to imagine what they’re thinking? What is your opinion on having ready-mades available in your office? Leave a comment below on how you handle the question of ready-made readers with your patients.  Or leave a comment on the best ways to communicate with your patients. We would love to hear your ideas.

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ARE THERE SUPERPOWERS IN OPTOMETRY?

Reading time 3.26

Ever thought about your superpowers?  Sure optometry allows us to help our patients by taking care of their eyes and visual system.  That’s the reason we all wanted to become optometrists.  It also allows us to make a decent living and provide for our families.  But did you ever stop to consider the superpowers it also grants us?

OUR SUPERPOWERS

What am I talking about?  Here are some of my thoughts on our special powers.  We develop excellent night vision from all the hours we spend in a dark room.  My patients often comment about me writing my clinical notes in the dark (in the days before EMR). But, I think nothing of it.  I have become adept at dark adapting and functioning quite well in the dark.

We have great strength in the arm and shoulder muscles allowing us to keep our arms elevated for long periods of time while we refract our patients. This is especially true when faced with that patient who wants to see every choice two or three times.

Our thumbs are powerful from popping lenses in and out of frames.  Strong thumbs and fingers are also vital for prying our patients’ lids open. And even more challenging is keeping those lids open long enough for an examination or instillation of drops. 

We have an odd superpower of being able to recognize the front and back surfaces of transparent materials.  Once we develop this skill, we don’t think about it much. We use this skill daily when examining the cornea and the lens. 

But, it also comes in handy when we inspect lenses for defects and scratches and it allows us to identify the damaged surface.   It is useful when cleaning spectacle lenses, or in windows when at home.  We can tell if a scratch or smudge is on the front or back surface of a pane of glass or a windshield.  I took this skill for granted. I thought that everyone could do this.  But, it turns out to be somewhat unique to ocular fields. It is possible that others may share this ability. However, I still think it is unique enough to qualify as one of our superpowers.

Our spatial awareness is keen since we must reverse right and left for patients all day long. But, there is a down side to this.  When I am giving directions, I actually have to stop and think since my brain is so programmed to reverse right and left for my patients. My sisters know it’s better to watch which way I point rather than listening to what I say.

Weird math skills are also in our arsenal.  To be honest, they’re not really weird, just not skills most people practice anymore. We need the ability to do math in our heads. How many times a day do we transpose a prescription from plus to minus cylinder, calculate a spherical equivalent or just do lensometry?   

But it turns out that we do other things that throw off most people. We are comfortable with both positive and negative numbers.  We have no trouble adding or subtracting numbers with unequal signs.  Subtracting a larger number from a smaller one doesn’t throw us like some people.   If you don’t believe me, then ask someone to subtract- 5.25 from +1.75.  For us, it’s just basic lensometry.  Additionally, we are adept at working with decimal points and especially good at dealing with .12 and.25 increments. 

And let’s not forget the metric system that confounds most Americans.  It’s a snap for us as we move from metric to English measurements while explaining findings to our patients.  Imagine a patient leaving our office confused, and likely depressed, if we told them they had 6/6 vision in both eyes.  Or if we told them that most people work at 40 cm (16 inches) at near.

OUR TRUE POWERS AND ABILITIES

Joking aside, we know these are not true superpowers. Yet do our patients understand what we really do in an eye exam? I suspect they know our ability to diagnose and treat eye disease and refractive errors.  But do our patients know we are looking for ocular complications of systemic disease and medications?  Are they aware we are checking their neurological status? And that we need to be up-to-date on optics and the design of both lenses and contacts. Do you teach your patients what an eye exam is and how it differs from screenings they may receive other places? If not, perhaps you should consider explaining how much we are doing.

All super heroes require a costume and alter-ego. I’m not sure what ours should be. Do you have any ideas?  Perhaps, we just need a discrete little cape added to our lab coat or maybe an emblem with a giant eye or glasses. I’m not sure what our super hero would wear, but I am certain that our alter-ego would be wearing a great set of glasses (like Superman/ Clark Kent).    

 

Can you think of any optometry superpowers I missed?  How about suggestions for our costume?  Please leave any comments in the section below.

 

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AMBLYOPIA-CAN WE DO BETTER?

 

Reading time  5.18

The Problem

Do you ever get frustrated when a patient presents with a preventable problem?  Whenever I see a patient like this, I feel compelled to review my attempts at patient education.  Did I do enough?  Is there something else I could do that would be more effective in the future?

The source of my recent discomfort was a child with bilateral refractive amblyopia.   I have practiced for more than forty years and can’t believe this can still happen.  With all the advances we have made in other aspects of eye care, I would have thought we could have made some progress in this area too.

How can parents still be surprised that their child needs a professional eye exam before they attend school?  Many people still don’t know amblyopia is preventable, especially if caught early.  And for that matter, the public doesn’t know that amblyopia does not mean an eye “drifts”. These are facts that the general public can’t seem to grasp.  Speaking for myself, I know that I need to do a better job educating the patients in my care.

The patient I mentioned happened to be the nine year old son of a good friend and long-time patient of mine.  Her son appeared for his first eye exam at age nine.  He is a good student and plays on several different basketball teams.  Not only does he play on several teams, but also happens to be one of their best players.  He is a perfect example of a child who shows no visible sign of any eye problems.

I can’t say his parents don’t care because his parents are attentive and would make sacrifices to be sure their children didn’t suffer in any way. I won’t go into detail on all the clinical findings. Suffice it to say, his best corrected visual acuity in both eyes was only 20/50-.  His refractive error was more than five diopters of hyperopia with some astigmatism in both eyes.

I am optimistic that with therapy and close follow-up, we will be able to reverse some of his amblyopia.  Still his findings made me consider what I can do to step up my education of parents in my practice.

Patient /Parent Education

I am disturbed by any child who presents with amblyopia, but this one hit me especially hard.  Patient education is a big priority for me.  Telling parents that their children need a full eye exam between the ages of 3-5 is standard in my practice.

I point out that pediatrician and school screenings can miss many problems.  The development of the visual system is discussed.  Information is given on how amblyopia can develop.  I also share that the earlier the risk factors are detected, the better then outcome will be. But, even with that, it still allows children to slip through the cracks and develop amblyopia anyway.  I don’t know what the answer is, but I think it is something we need to consider.

We are all faced with the dilemma of deciding how to keep the levels of our care as high as possible.  How do we provide quality care, but also educate our patients?  Patients expect us to provide excellent care for their current problems. Though unspoken, patients also expect us to advise them on how to guarantee that their vision stays good for their future.

A Unified Approach

It is possible to change public opinion.  We can do a better job teaching the public about children’s eye care. It’s not impossible. When I get discouraged, I always think about the example of dentistry. They have educated new parents well. No parent would wait until school for their child’s first dental appointment.  Nor would they wait until their child complained about their teeth to take them to a dentist.  Yet, parents just assume that they will know if their child needs eye care.  Or worse, they have the false security that a screening will pick up any visual problems their child might have.

AOA began a public education campaign about the importance of early eye care when InfantSEE® launched.  There were a lot of public service announcements then, but they seem to have disappeared.  Ophthalmology has not done any better at educating the public.  And I’m not sure if all pediatricians are even aware that their screenings can miss potential problems.

A possible good start on changing the narrative on children’s eye care would be to team up with pediatricians and ophthalmologists and present a unified message to the public.  Pediatricians are vital to preventing amblyopia since they are always the first, and maybe the only doctor, to see infants and toddlers. Just as they instruct parents to take their children to the dentist, they could also emphasize that children need a full eye exam by an eye care practitioner.

It would be wonderful if all professions involved in the care of children could join forces to educate the public.  Even better would be enlisting the help of an industry leader in children’s health to underwrite the cost to get the message out.  That is well beyond what I can do, but would be a great dream for the future.

Begin in your Community

In the meantime, there is nothing to stop us from trying to make changes in our own communities.  We can work with the schools, pediatricians and ophthalmologists in our communities to come up with a plan that everyone can support.  Talk with local pediatricians and share with them your concerns about preventing amblyopia and identifying children who are at risk. Discuss the problems with screenings instead of full exams.

I think the responsibility comes back to each doctor in his/her practice.  We educate our patients about cataracts, dry eyes, glaucoma and macular degeneration to name a few.  But, be honest with yourself, how often do you discuss the importance of early childhood eye exams and the prevention of amblyopia?

I have thought long and hard about how to approach this with my own patients.  Since my time in the exam room is at a premium, I need to think of other alternatives to help.

I have no new revolutionary ideas to present.  Pamphlets, flyers or posters around the office could help. Creating a special education campaign could be part of your Back to School efforts. Giving a handout to all parents with children is an obvious possibility. Printed materials are helpful, but the problem is they don’t always get read. Providing additional information on our websites, blogs and social media platforms can be useful, but only if a parent chooses to read it.

For these reasons, I concluded that I must make an effort while parents are in my office when I have their full attention.  I will continue to make a renewed effort to provide information on childhood visual problems. That presentation will stress our ability to prevent these problems.  Without us providing the answer to why early eye care is so important, our efforts may fail.

This educational effort may be a place where we can all learn to delegate. If we don’t have the time, then maybe we should consider training one of your staff to take over that duty. Our staff could also be an effective addition to the other educational efforts in our office.  Most offices use staff effectively for contact lens training, so why not consider expanding that to cover other issues.

No parent wants to neglect their child’s health.  If we provide them with the proper information, hopefully they will make the right choice.

Every doctor needs to consider how to handle this best in their practice.  We need to address amblyopia prevention if we expect to provide the best care we can to our patients and their families.

 

What measures do you use in your practice to educate about the importance of early childhood eye care?  Do you use your staff to help with education efforts? Tell us how you handle pediatric care in your office and leave ideas that may help others in their practice. Please leave your comments below and join in this important discussion

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SHOW AND TELL- EDUCATION FOR OPTOMETRY

Reading Time 4:13

 

Recently I realized how important show and tell can be in taking care of our patients.  We all learned early in our careers to never assume a patient knows how or what they should be doing. For that matter, are they actually doing what they say they are? On our tight schedules, it is so easy to just accept what our patients say.  But, the fact is we can’t trust them to always tell the truth for a variety of reasons.  Leading that list of reasons is that the patient knows what they’re doing is wrong.  They don’t want to confess their shortcomings because they know a lecture will soon follow.  We must also wonder if our patients ever received the right instructions in the first place.  This is especially true with patients who are new to our practice.

All doctors have their own set of horror tales of patient education gone wrong.  It takes time, listening and careful questioning to make certain that our patients understand our instructions.  Even then, it is no guarantee that they may not do something that could affect their treatment and final outcome.

Last week, I had a man come to my office for his exam.  He began by telling me that he works in a dirty environment and that he has dry eyes.  Artificial tears were used to help the dry eyes. The dirty environment meant he needed to wipe his lids while at work.  I could have let it go at that, but I wanted to know more.  Upon further questioning, he said he used the tears when he felt his eyes were dry. There was no routine frequency of use.  When I asked how he wiped off his lids, he offered that he was using alcohol preps!

As I continued the exam, I saw a notation I made on his last exam. I noted that he was a poor responder on refraction with variable results on his last visit.  On external exam his eyes looked irritated. Based on that and my note from his previous visit, I decided to use some artificial tears to improve the quality of his tear film for the refraction.

I opened a trial bottle of artificial tears, but instead of putting them in myself as I usually do, I decided to let him do it instead.  What I saw shocked me.  He ran the bottle along his lids just below his lash line. He administered approximately 4 to 5 drops, none of which even looked like they made it to the eyes.  The tears ran down his face and there was no doubt the bottle was now contaminated.  And that was in a clean office environment.  Imagine what happened to him on a daily basis while at work in a dirty environment.  This was the worst attempt at instilling drops I had ever seen.

I was thankful that I had given him the bottle instead of just doing it myself.  Valuable information would have been missed in how I advised him on his future eye care.  I would have assumed that he knew how to instill drops since he offered that he was doing it on a daily basis.  The treatment I suggested wouldn’t have been successful since the drops weren’t handled correctly.

I took the time to instruct him in the proper way to instill drops and then watched him do it several times in each eye. Yes, it took some additional time, but it made the difference in whether the total treatment plan succeeded. Needless to say, he was also instructed to abandon alcohol preps as a lid wipe and alternative treatments suggested.

I couldn’t help but think of all the patients I prescribe drops on a daily basis. Artificial tears, rewetting drops, allergy drops, and medications are all prescribed routinely.   But, how many times have I stopped to make sure their technique was proper and efficient?

Another Lesson Learned

I also learned another lesson about instilling drops from my own mother.  She has a dry eye as well.  I gave her artificial tears and told her how often to use them. In her case, I had showed her how to instill the drops and watched her do it several times.  A few days later she told me she was having problems.  So when I was at her house, I asked her to show me how she was using the drops.  Her technique was good except for one major thing.  She was trying to do it while standing up.

I never thought to tell her to only attempt instilling drops from a seated or supine position.  I realized that I had never included this piece of information to any of my patients.  But, I have since changed my instructions. I had never considered that a patient would attempt putting in drops while standing. The possibilities of losing balance or falling while instilling drops concerned me.

This is especially worrisome in the elderly patients who are often the ones most likely to need drops. They are also the group most likely to have problems with balance. I now make the suggestion that they only use drops when seated or laying down. Of course, it is possible to put drops in while standing, but it is more difficult.  Having a patient tip their head back can cause problems with equilibrium and could precipitate a fall.  Why not err on the responsible side and give patients instructions that keep them safe?

Show and tell may seem like an antiquated children’s game, but in my practice, it has become a valuable adjunct to my verbal patient education.  We would never think of dispensing contact lenses to a new wearer and not offering instructions in their care and handling. I don’t know of anyone who would expect a patient to learn how to insert and remove their contact lenses on their own.  Maybe we need to think about our instructions in other areas of eye care as well. If there is no time in your schedule for this instruction, then why not consider training one of your staff to become your patient educator.

Have you ever experienced problems with patients harming themselves by doing something wrong? Have any of your patients not gotten the proper results because of an error in the way they used the drops?   What do you do in your office to be certain patients learn proper procedures?  Do you use your staff to help in educating your patients?  Leave your comments and suggestions below.

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HOW AN AD HELPED OPTOMETRY AND OUR PATIENTS

Read time 3:04

This may not be breaking news, but there is still a valuable lesson to be learned.  In August 2016, I began to notice a new commercial related to eye care.  It was somewhat of a media blitz.  The subject- dry eyes.  The company –Shire Pharmaceutical.  As an optometrist, I realized the ad campaign was obviously in advance of their launch of Xiidra (lifitegrast) in the fall of 2016.

Aside from the anticipated potential of this new drug, the launch of this media campaign was a novel and inspired one.  It has been one we can all learn from.  Nowhere in their initial commercials or on their website was there any mention of their drug. The purpose of both the website and commercial was not selling the drug. Instead, they set out to educate the public about dry eye and its consequences.  We benefitted from this campaign, as do our patients, since it helped direct people with symptoms of dry eyes into our offices for diagnosis and treatment options.

The campaign featured Jennifer Aniston as a spokesperson which, in my opinion, is a definite plus.  She is popular with both men and women, though these commercials are obviously aimed at women. Directing it to woman makes sense since women suffer more from dry eyes than men. Women also schedule most of the appointments for family members and make decisions on health care and other purchases.

The website, https://www.myeyelove.com/, is consumer friendly.  I suggest you visit it and see what it says and the way information is presented.  Information is easy to understand.  The website is simple to navigate.  There are many videos that feature both optometrists and ophthalmologists. Both professions are depicted as capable and helpful.   The advice is common sense.  They encourage the viewer to seek out an eye care professional and have their symptoms evaluated.

Although I am not a fan of all the business to consumer (B2C) advertising done by pharmaceutical companies, I do like this ad campaign.  It does not set out to sell their product, but instead to educate the patient and consumer.  The company realizes that getting people into the doctor’s office will translate into more business for them.  But, a second benefit is that their company’s intent seems benevolent instead of opportunistic. They are not seen as just making a profit from a patient’s misfortune.

They could have just marketed it to doctors, or chosen to market it like other companies have.  But, they took the high road and took a novel and different approach.  Kudos to them.

With the official launch of Xiidra, the commercials run by Shire Pharmaceutical have changed and are more like ads we have seen in the past. They run ads for Xiidra as expected, but interestingly, also continue to run ads for My Eye Love. They have a separate website for the drug but also maintain the more information and education driven site for My Eye Love.   Both websites continues to be informative and easily navigated.  Links exist between the My Eye Love website to the Xiidra site, but it is up to the visitor to choose to use the link. It would have been an easy, and cost saving, decision for Shire to discontinue the My Eye Love ads and website when they got approval to market Xiidra.  Yet, they chose to keep both going.  Another reason to admire them.  I applaud their continued efforts on educating the public.

What can we learn and apply to our practices?  Educate your patients.  Provide quality care.  Make your marketing approaches aimed at what the patient wants and needs and not on what you think they should want and need.  Do not sell.  If all your social media activity and personal communication in the office are centered only on selling and promoting yourself, you will lose your credibility as a caring professional.   “Buy a new pair of glasses”, “Look at our new frames”, “Schedule a new exam” are ok in their place. Just don’t make it the only message you deliver.  In a study done by SproutSocial, 46% of social media users unfollow a brand because they have too many promotional messages.

Don’t miss the opportunity to educate your patients and make a more meaningful connection to them.  It is communication and connection that builds a practice and keeps patients loyal.  Make sure your patients leave your office as an enthusiastic ambassador for your practice.

How do you educate your patients on a daily basis in your offices?  How do you show your patients that your primary interest is in their health and well-being and not in what you can sell them?  Leave your comments and suggestions below.

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COMMUNICATION LESSON FROM AN UNLIKELY SOURCE

Reading time: 3:52

I called a plumber to repair a dripping faucet in my bathroom.  He was prompt, efficient and competent.  I asked him about other work I might need done in the future.  I just wanted an estimate of the approximate cost.  Instead, what followed was a detailed discussion about all the possibilities; shut off valves, taking faucets apart, non-freeze faucets, thickness of walls and on and on.

My eyes started to glaze over after a few minutes. He was knowledgeable as he attempted to explain everything to me and to answer all my questions. I tried so hard to hang in there and make the appropriate responses. Despite my efforts, it was a losing battle.  Midway through his long explanation, a horrible thought came to me- Is this the way I sound to my patients?

I’ve always prided myself on educating my patients, but now I was doubting myself.  Do I use terms and concepts they don’t understand?  Do I go into too much depth, or too little?  Am I paying attention to their responses or am I tuning them out?  Do I continue on with what I think they should know no matter what?  I can get quite passionate about what I say and do.  I love to educate a patient who wants to learn. But now I had to ask myself some tough questions.  Am I responsive to their needs? Am I making an effort to answer their questions in a way that is meaningful and useful to them?

Tailoring my response to the individual patient has always been a goal of mine.  Watching a patient’s facial expressions and body language is an important clue if I’m hitting the mark or talking over their head. For some patients, I go into great depth because their follow up questions and responses show they want to know more.  For others, who just want a simple answer, I try and provide that as well.

My experience with the plumber was a great reminder to always stay tuned in to my patients.  My answers can establish a valuable connection with my patients.  We are all facing increased pressures to see more patients daily and that means less time to make a valuable connection.  It becomes more important than ever to maximize that time and make a good impression.

I feel there are some basic rules to enhancing communication.  Most apply to any type of conversation, but especially when dealing with technical concepts.

  • Don’t use technical jargon.  It doesn’t impress patients or make them understand any better.  It sounds condescending and makes you sound like a medical snob.  Find a way to make it understandable without talking down to patients.  Making the effort to be sure they understand shows you respect them. It also conveys the message that they need to take part in their own health care.
  •  Make eye contact.   Whether you’re answering their questions, discussing the results of the exam or telling them the recommended treatment, be certain to look at your patient.  Resist the temptation to be entering data on the computer while you’re talking to them.  I know this can’t avoided through much of the exam.   Today’s electronic records necessitate that we record results as we go through our exam.  But be aware, when you are facing the computer, patients can’t read your expressions.  For that matter, they can’t hear you as well either.  Your head is often turned away and faced downward.  Your voice is absorbed and muffled by the surfaces in front of you. This is especially important to remember with elderly patients who often have problems hearing.
  • Body language can also speak volumes.  Face your patient whenever possible.  Make sure you’re open to them. Arms crossed on your chest is a closed off signal.  Standing, walking away or placing your hand on the door suggest you are already moving on to the next item on your schedule.  All of these give an unconscious message that you are no longer engaged with the patient.
  • Explain with simple examples or imagery.  Learn to use common sense examples or create visual images that’ll be difficult to forget. Both of these go a long way in creating a powerful memory for the patient.  If a patient is well informed and educated, they are more compliant. The time spent explaining also makes a valuable connection between you and your patient.  Never waste that opportunity. You may never get another chance if they don’t return to your office.

These suggestions aren’t profound.  Nor are they difficult.  I suggest listening to yourself explaining some common information.  Record yourself if you need to, or have someone else listen and give you a critique.  Try and improve your explanation by avoiding all the technical jargon that slips in when we are unaware.   Sometimes it’s necessary to use technical terms, but if that’s the case, then define them first.

Listen to your staff too.  Everyone in our offices is accustomed to using a shorthand of abbreviations and medical terms when we talk to each other.  It’s so easy to slip and use these terms when we speak to our patients.  Some patients will ask what you mean. But, many patients will not because they don’t want to look stupid.  Make your staff aware of good communication skills. Discuss it at staff meetings or perhaps role play. Have a staff member explain a problem, treatment or a sales presentation to another staff member.  Have other staff members make suggestions on how it could be improved.  It can be a valuable learning experience for everyone.

No patient should leave without understanding their diagnosis and treatment options.  Your patients will notice the time you spent making sure they understood.

What do you do in your office to improve communication? What tools do you use to help patients better understand their conditions? Join the discussion. Write your comments below. Visit our website and social media for other suggestions and free resources to enhance communication skills.

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DEALING WITH THE FEARFUL, ANXIOUS PATIENT

Reading time 3:30

My dog is a more cooperative patient than many patients who walk in my office door.  I am blessed with a wonderful Golden Retriever named Champ.  He developed an eye infection. Antibiotics and steroids have not resolved the infection. So I decided to seek out the advice of a veterinarian specializing in ophthalmology.

In their office, a technician reviewed the history.  A Schirmer’s test and tonometry were performed without a topical anesthetic.  Champ didn’t pull away, turn his head, squeeze his lids shut, or make any sounds of whining or growling.  He just let her perform the necessary tests.

The veterinarian did an external evaluation, hand-held slit lamp and binocular indirect ophthalmoscopy.  He instilled fluorescein and retracted the nictitating membrane. In all this time, Champ was the model patient.

Observing Champ’s exam, it occurred to me how nice it would be if all my human patients were like Champ.  Most uncooperative patients don’t set out to be that way. But, it still creates a frustrating and challenging exam for both patient and doctor. Along with the frustration, there’s also the fear of missing something or obtaining inaccurate findings under these less than ideal situations.

There’s not one simple explanation for lack of cooperation nor one universal solution. One frequent cause is fear or anxiety.  If you suspect that is the reason, then try and identify the source.

Is it fear of making the wrong choice and concern this will harm their eyes?  Is it fear that they will lose their vision?  Do they have high levels of anxiety associated with medical exams of any type? Do they have a history of a bad experience?  Do they dislike having their lids touched?  Do they object to the bright lights?

Whatever the reason may be, try and allay their fears. But, a word of caution, don’t lie or minimize possible discomfort associated with a test or procedure.  I may not tell every detail, but I do tell my patients what to expect and I answer their questions honestly. After all, they will soon experience the procedure themselves. If you lie, you will lose the patient’s trust. Once you have lost trust, it may not be possible to regain it.

Whatever the reason for their fear, I find that good communication is key.  Take the time needed to explain and reassure them as you perform the tests. In the long run, it will actually save you time. If you try and rush your patient through the exam, you will escalate their anxiety and further decrease their cooperation.  You will have to repeat tests and still end up with a poor and unreliable result.   Both doctor and patient will feel stressed and depleted by the end of the exam.

Acknowledging and discussing your patient’s fears actually calms the patient down.  Being empathetic and normalizing those fears can have a major impact on the patient.  I stress that it is natural to have concerns about medical tests. In fact, I confess that my own weakness is having a throat culture done. Letting your patient know that you also find some tests difficult, allows the patient to make an important connection with you.  Connection facilitates the exam.  Fears often embarrass patients.  Putting yourself in the patient’s position decreases their embarrassment and increases their cooperation. You haven’t added to their shame, but allowed them some dignity.

It is within your power to help them relax.  Share with your patient ways that they can make it easier on themselves.  Deep breaths are a proven method of relaxing and centering the patient.  For that matter, some just need to keep breathing.  (I’ve observed that many patients hold their breaths when anxious).  Simple advice can work for many patients.

When a patient can’t keep their eyes open for pupil testing or are photophobic, have them look up.  It may not be ideal, but you can still see the pupillary response. The patient is more comfortable and that is preferable to forcing their eyes open and trying to make an evaluation.

Whenever possible, allowing a patient to have some control can also help.  I ask my patient to tell me when they are ready for a test so they can prepare themselves instead of surprising them. They might want to hold their own lids. If so, let them try.  Instruct them on how to hold them without getting their fingers in your way. Show them how to have good control without exerting too much pressure on their eyes.  I am often surprised at how allowing them lid control can work and if it doesn’t work, at least the patient knows you tried it their way. These simple steps can make a difference in the exam and its results.

Fearful and anxious patients are appreciative when you make the effort to treat them with kindness and compassion.  It would be wonderful if all patients could be as cooperative and reliable as Champ, but the fact is many can’t. Remember that your attitude and approach to them can sometimes make a difference.  Why not try to make the exam more pleasant? You have nothing to lose and everything to gain.

What helps you when faced with an anxious or uncooperative patient?  Share your comments below and let’s begin a discussion.

 

 

Posted on

THE BIONIC WOMAN AND PHYSICAL DISABILITIES

Photo by rawpixel on Unsplash

Reading time 4:18

I am a bionic woman. After many surgeries, I am now the proud owner of two artificial knees and two artificial hips. Performing daily activities and being independent are wonderful gifts that many of us take for granted.

I learned valuable lessons while my joints were failing, and as I recovered from my surgeries.  What I learned from my experiences can be applied to the patients in all our offices. There are many people who are considerate when faced with someone who needs help.  Yet, I am still amazed at how many people seem oblivious to the challenges other people face. I am always stunned when this neglect occurs in a health care setting.

When using a walker, crutch or cane, entering a medical office is the first of many challenges. Look at the door to access your practice. How does it open?  Does it require a pull or a push?  Both can be tricky. If a patient is not alone, no problem.  But if they are alone, the struggle begins.

Let’s talk first about the doors that pull open.   A patient must step back to open the door. Then they must try and thrust themselves into the doorway to prevent the door from closing.  Not exactly a safe maneuver.  And if the door opens in, the patient has a new set of challenges. Both hands are on the walker or crutches. So the patient must use their head, shoulder or walker to push the door open.  Not exactly a graceful entrance and it can throw a person off balance. And if there is a vestibule with two doors and a small space between them, life gets even more interesting.

Understand that if a person is using a walker or crutches, they are using them for support and strength.  Removing a hand from the walker or crutch can affect a patient’s stability.   I am amazed when office staff and patients in the reception area can watch someone struggle without offering help.  We can’t control how other people respond. But, we can make certain our staff is aware of the importance of helping when a patient is struggling to navigate our offices.  Think about the positive impact of offering a helping hand without waiting to be asked.

Furniture selection for the reception area is important. Chairs with straight backs are good for patients using a walker or cane.  Sitting on furniture that is too low or too soft is disastrous for someone with physical disabilities or the elderly.  Also be certain you have several chairs with arms in your office.  People with disabilities learn that it is never safe to use their walker for support as they stand. Walkers can tip forward and cause a person to lose their balance or fall. Patients learn to use the arms on a chair to push up to a standing position and then safely transfer to the walker.

Many times I heard my name called at a doctor’s office to go back to the exam room.  The technician or nurse was halfway down the hall while I was still trying to get out of my chair.  I was already self-conscious about how slow I was moving, but the tech rushing away only made me feel worse.  My response is to hurry to try to keep up, but this is not actually safe. When someone is in pain or recovering from some injury or surgery, I can assure you that they are not moving slowly to aggravate you.  They are moving at the speed that allows them to feel safe and stable while minimizing their discomfort or pain. Slow down!  The exam can’t start until the patient arrives in the room. So show them respect and compassion.  Reassure the patient that you want them to take the time that they need.

Changing positions from seated to standing can take some time as well. It is vital that the patient feels secure before moving. Many people will stand still for a moment to get their weight redistributed and muscles engaged.  Then, when comfortable, will begin to move forward. Generally, allow your patients to get up on their own.  When a person has to use a walker or crutches, most will learn what works best for them.  You can politely ask if they need or want your help, but don’t force it on them.  If they do want help, ask them what they want you to do, rather than presuming you know.

Your staff can assist your patients in many different ways.  Just being aware of physical limitations is a start.   If the footplate on the examination chair is in a raised position, it allows a patient to walk up to the chair, turn and sit.  When they feel the chair behind their legs, they can then lower themselves onto the chair using the armrests for support.  Staff can then move the walker, cane or crutches out of the way for the examination. Never ask a patient who is disabled, either temporarily or permanently, to step up on the footplate and then try and turn around to sit in the chair. Once they sit, ask if they want the footplate put back down.  Most people will want this unless they have long legs.  Another source of discomfort is letting legs just hang with no support under them. It can be very painful, especially on a post-surgical patient since gravity will pull the leg down.  If their feet don’t reach the footplate, place a large book or platform on the footplate to support their feet and relieve the pull on their legs.  This also applies to people who are short.  Try and make your patients comfortable if at all possible.

If the patient had surgery recently, staying in one position without being able to move can make the patient uncomfortable.  When they are uncomfortable, they can’t concentrate and respond well.  Be aware of this.  If a patient is moving and repositioning themselves a lot, ask them if they need to stand or move.  Just changing position or moving a little can relieve this discomfort. Sometimes offering a small footstool and allowing them to elevate their leg will also help.

These are all simple and inexpensive things to do that can have a big impact. Being aware of your patient’s needs and limitations and responding appropriately will mean a lot to your patients.  They will remember your kindness and consideration.

What ideas do you have to make your patients more comfortable?  Share them below in the comments section.