In the land of optometry, peculiar characters have made appearances in the exam room. Unique as they come, each requires an individualized approach to the exam and treatment plan. Tales have been told about one or two of them, but never before have all seven been exposed…until now.
Disclaimer: You may think you recognize these names from a story told long ago. Beware, these patients can bring your day from a high to a low. So buckle up and get ready to learn; follow this advice and the tables will turn.
Doc: The Engineer
Years of schooling and countless continuing education courses are no match for this patient…or so he thinks. He can challenge your diagnosis, recite optometric literature and engage in discussion about nuances in treatment. He is detail oriented, scientific and his blood type is A.
The key to an efficient exam for this patient is to limit the options and leave ample time for patient education. If you spend a lot of time refracting you will literally be spinning dials ad nauseam. Choice one will never be better than two; in fact, it will be 80-85% better. However, choice three will be 95% better so the patient will need to see all three choices again…and again. In this patient population, trial frame demonstrations can also exhaust time so unless there is a huge change in the prescription, finalize it based on your best judgment.
Doc is very interested in his eyes so he will attempt to engage you in conversation throughout the exam. Plan to multitask yet recognize how to segway from one test to another. Rather than describing every test as you perform it, describe a cluster of tests before you perform them. For example, you can say “now I’m going to test your eye teaming skills” and conduct your battery of binocular vision testing.
Preface every exam with Doc by saying that you will be performing a comprehensive analysis of his prescription, eye teaming, and eye health. Answer questions as they arise, but if the volume is high direct the questions to be answered at the end of the exam. You must allow yourself time to examine the patient efficiently without several interruptions that could make you run behind.
Grumpy: The Unhappy One
From the moment he walks into the office, this patient wears a frown that needs to be turned upside down. His complaints run longer than the naughty and nice list and he will undoubtedly express dissatisfaction about his past experiences in eye care. He is disgruntled, opinionated and his patience is running thin.
As luck would have it, this type of patient seems to appear on a day when you’re running late (probably because of the former patient). If this is the case, begin your exam with an apology for making him wait and expressing that you value his time. Fruitless as it may be, most people have a hard time arguing with an honest apology. Highlight that you provide a comprehensive visual analysis to every patient, hence complex cases can cause minor delays in the schedule.
In the exam, limit the number of chief complaints to what you can accomplish that day. As optometrists, we are tempted to solve all our patients’ problems. However, it takes a skilled clinician to be able to prioritize based on the patient’s needs. Narrow the list to the three biggest complaints that he has about his vision. I guarantee you that he can think of more than three, but putting a cap on the amount encourages Grumpy to prioritize his visual needs.
Unlike the former patient, trial frame demonstrations are key for Grumpy and it will help you avoid a re-do. Proof of improvement in clarity may also elevate the patient’s mood because he feels cared for. Perform a problem-focused exam so you can address his complaints and educate him about the treatment plans at the end. Reiterating his three biggest complaints from the beginning gives him the impression that you were listening and actually catered to his visual problems.
Sleepy: The Fainter
Although he may appear as a run of the mill patient, this one is a doozy. All your preparation goes out the window as he hits the floor. He can be the biggest and the strongest, most friendliest of all patients. Don’t let the witty banter fool you, but beware when it stops.
Dealing with a patient who faints in your office may elevate your stress levels, but try to remain calm and provide palliative treatment. Recognize the signs that someone is uneasy so you can take the necessary precautions. Signs that a patient may faint include increased perspiration, confusion, flushed appearance and abrupt silence from an otherwise chatty patient. Often, patients who begin to feel lightheaded during the exam will ask to be excused for a restroom or water break. They do this to avoid embarrassment, but they actually end up putting themselves in a dangerous situation. It’s important to consider that a patient who asks for a break may be at risk for fainting.
At times, you will ask all the right questions and look for all the signs, yet it happens. The drops are in and the eyes are rolling back, your patient is having a vasovagal response (that’s what the fancy kids call it). As previously mentioned, the most important thing for you to do in this case is to remain calm. Additionally, stay present with your patient. It’s a common response to run out to the room to call for help, however for their safety you must not leave the exam room. So open up those lungs, clear up the vocal cords and yell for assistance.
If the patient is in the exam chair, recline the chair and elevate the patients legs. This allows maximum blood to reach the brain and reduces the time for the patient to regain consciousness. Check the patient’s pulse and breathing to decide if further medical assistance is needed. Most of the time the patient will regain consciousness within a couple of minutes. However, if they don’t or if they experience additional symptoms such as numbness, chest pain, severe headache etc. call 911 immediately.
Once your patient regains consciousness it’s important to keep them lying or seated in the chair. Avoid giving them any food or drinks until they are back to baseline; this prevents choking hazards if another episode were to occur. Your patient will be tempted to run to the restroom to regain composure, however stress the importance of staying immobile to prevent another vasovagal response. After 15 minutes re-assess the signs and symptoms for full recovery.
Schedule a follow-up with this patient because after this episode he is done for the day. Advise that he return on a day after he has eaten a good meal and is well rested.
Dopey: The Energizer
Perk up those ears and remain vigilant because Dopey is about to take you on a bumpy ride. Roller coasters have made fewer twists and turns than this patient; be careful because misdirection is his forte. He has high energy for the exam but low tolerance for tests. With Dopey, trickery will get you far so get ready to think outside the phoropter.
Work, work, work, work, work. Time is of the essence so you want to maximize your efficiency during this exam. Dopey’s attention span is limited and you have about 20 minutes before he decides that the exam is over. Subjective responses will take you all over the place, but objective tests will save the day. Learning how to manipulate a few pieces of equipment to perform all the tests will minimize the struggle.
Start with a game. This is an excellent way to build rapport with this patient and gives you a lot of information about the visual status. Put on some magical glasses and find the shapes in a stereo book. You will gain insight into his visual acuity and binocularity. Next, say goodbye to the cover paddle. Use your hand for monocular aculites and a swish and flick of your finger to master the cover test. Dust off the cobwebs from that retinoscope and attempt free space retinoscopy. Avoiding the phoropter will save you time from chasing the patient as he tries to escape a foreign contraption.
Sitting in an instrument is a challenge for Dopey so your autorefractors and optos don’t stand a chance. If slit lamp is a struggle grab your 20D and recharge that BIO to analyze the anterior segment. Avoid playing yank the eyelids while instilling drops, instead place a drop into the nasal canthus then advise the patient to blink. You’ll be happy to remain friends after.
The carrot is better than the stick so establish a reward system to motivate the patient. Keep a bag of stickers at hand and don’t be afraid to use them as needed.
Bashful: The Symptomless Patient
He has complaints but he won’t share, all optometrists should beware, this patient requires keen observation. He will never win an award for the best historian so you must dig a little deeper to uncover his condition. Watch for the ocular signs as they will surpass the symptoms.
This is the infamous patient who disappears and shows up one year later to his 3-month follow-up for glaucoma and diabetic retinopathy. He uses his drops monthly rather than daily because he’s a friend to the environment. He has a knack to score off the charts on his A1c test, and his blood pressure continues to amaze. However, his only complaint is that he needs a new pair of glasses, of course.
Naturally, based on case history, testing for this patient will require every minute of the exam. Along with supplementary testing, you will need to spend an abundant amount of time on patient education. Improving patient compliance can be a tricky thing. This takes us back to the carrot or the stick concept. On the one hand, you want to instill a little fear so that the patient follows your treatment regimen but on the other hand you don’t wanna scare them so much that they never return. I find that patients often don’t realize that a lack of symptoms does not mean that their eyes are healthy. A careful explanation, picture demonstration, and emphasis on how vision can be affected by systemic health can produce a positive outcome.
Moving forward, set goals with your patient and keep a close follow-up especially if they are at risk to play Houdini. If the patient reports that he simply can’t remember to instill his artificial tears or his glaucoma drops suggest options to aid his memory. Often times, a reminder in a highly accessible place such as a bathroom mirror or a refrigerator can make all the difference. It’s also important to assess his home life. If the patient lives alone, he may have a harder time remaining compliant so reminders around the house would be the key. Otherwise, get a family member or a partner involved in the treatment process to improve success.
Stress the importance of follow-ups appointments and educate the patient that his symptoms may not correlate with signs of the disease. Collaborate with the rest of his medical team and create a plan of action. In addition, dispense a list of goals to hold the patient accountable and revisit them at the next exam. Encourage him by demonstrating the positive outcome of his compliance. It can be the motivator which drives Bashful to make frequent appearances in your office.
Sneezy: The Walking Virus
Hide your staff and cover your face, this patient has an infection and he’s not afraid to spread it. He sneezes into his hand, his eyes are red with disease and his cough projects miles across the waiting room. He arrives punctually and lingers indefinitely while his energy infects every person in the room.
The first question that comes to mind when you see this patient is “why are you here?!” Sneezy has a knack of showing up as the last patient of the day. Alas, every patient deserves your A game so slap on some gloves and a mask and take the following precautions to minimize the spread of infection.
Be aware of any and all the equipment that he touches from the cover paddle to the chair because it will all need to be thoroughly disinfected. Viruses may be resistant to many kinds of disinfectants so make sure to use a virucidal disinfectant for maximal efficacy. Prioritize the tests that need to be performed that day. Vision, pupillary reaction, and EOMs are must, but in a patient with viral conjunctivitis, tonometry could be deferred to another visit. However, if it seems pertinent to the case use a disposable tonometer tip to reduce the risk of spreading the infection. The last thing you want to create is a nosocomial epidemic that traces back to your office.
Educate the patient thoroughly on the proper hygiene protocol for the duration of the infection. Frequent handwashing, changing bed sheets and copious artificial tears are necessary for most viral infections. Advise the patient to avoid physical contact with other individuals especially after touching his eyes. Discontinue contact lens wear for the duration of the infection. Often, this last piece of advice is hardest to follow for patients who are married to their contact lenses. Any contact lens wearer needs to have a glasses prescription–this should be an absolute requirement for patient safety.
Maintain a close follow up to make sure the vision remains stable and the patient’s status is improving. Depending on the severity of the condition this can range from 1 day to 1 week. Advise the patient to wear a mask in the waiting room at the next visit to minimize the risk of airborne infections as well as the risk of clearing out the rest of your schedule.
Happy: The Dream
Clap along if you know what Happiness means to you. You’ve had a rough day, but this patient is about to remind you why you practice optometry. He is grateful for your treatment from prescribing new glasses to catching a retinal tear, he remains complaint and his loyalty to you continues to grow your practice. In an alternate universe, Happy would be the last patient you see in your day. Maybe fairytales can come true so let’s say that day is today.
It is important to get to know this patient on a professional and personal level. Asking a returning patient about their family or reminding them of an anecdote that they shared at the last visit reinforces their connection with you as their doctor. After all, it is people with eyes that we treat, not just eyes alone. So next to all your pertinent findings from the day, jot down one or two things that you talked about that day. It may be that they just got a new pet, took a mini vacation or even that they are excited to try a new restaurant. Ask them about it at the next visit and witness the look of delight on their face.
Understanding how a patient operates on a daily basis not only helps you build rapport but also helps you recognize how they use their eyes. This helps you treat them to the best of your abilities and address symptoms that the patient may have perceived as unsolvable. For example, computer vision syndrome is on the rise in the workplace which can cause visual stress and eye strain. It is also very treatable with proper ergonomics, a glasses prescription or vision therapy. Your Happy may not know about his option to improve his work environment, but by revealing them you will continue to earn his trust.
Happy is a patient that you want to keep in your office. Unlike the former patient, this is the patient that you hope is contagious.