By Pamela Miller, OD, JD
The power of persuasion can motivate your patients to follow your recommendations, but documenting their actions (or inactions) when they are not compliant is part of protecting your practice.
Ask, Rather than Tell
Rather than simply write a prescription, or give my patients an order, I prefer to ask them to follow my advice, emphasizing their freedom of choice. Iletthe patient know what I feel the best course of action is, explain why I think it’s best andthen ask if they would be willing to do it. In the case, for instance, of a patient who is irritating her eyes by wearing eyeliner make-up on the inside of her upper and lower eye lids, Imight put my hand on my patient’s arm and say: “If you can justput the liner onbelow the lash line, it would be a lot healthier for your eyes. Putting it on the inside of the lidsblocks importantglands, which can lead to dry eye and infections. Could you dothat for me?”
Explain, Get Patient Consent
Just as I explained the rationale behind my behavior change request to the patient who was unknowingly irritating her eyes, I also am careful to explainwhat I do in the exam room, making sure my patientis agreeable every step of the way. Most of us know that if a doctor does an invasive procedure, he or she needs to have the patient sign an informed consent form. But fewer of us realize the importance of giving the patient the opportunity to tell the doctor they are not comfortable with the doctor’s actions during routine exams. If, for instance, I am dilating a patient’s eyes, I would give them a heads-up: “Now, I am going to put these drops in your eyes to dilate your pupils. If I hit, it should sting a bit and you will have trouble focusing for a few hours and your eyes will be more sensitive to light. But doing this will enable me to get a good picture of the back of your eyes, so I can ensurethat your eyes are healthy. Is that OK?”
Document When Patient Says “No”
Document as much as you can, both to enhance the patient experience the next time they return to your office, and to protect yourself legally. Make it an automatic routine to document first what you did to examine or treat the patient, what youadvised the patient to do; and what the patient decided to do. Sometimesthechoice the patient makes that conflicts with your advice isn’t serious, such as deciding to buyover-the-counterreading glasses rather than purchasing prescription quality eyewear.Document it, nevertheless,soat the very least you’ll know the next time they come in to take adifferent approach to convincing them tobuy better qualityglasses. If the patient insisted on glass lenses rather than myrecommendation of polycarbonate glasses, I would jot down in my records: “glass per patient.”
But more importantly, if the patient makes a choice, despite your best persuasive efforts, to do or not do something that will endanger their eyes, document your exchange with them, including exactly what you told them regarding what could happen if they did not do what you advised, and what they told you in response. If, for example, I diagnosed the patient with a visual field defect and asked that the patient come back by a certain date for an additional examination or treatment, and theydid not do that, I would document in depth my diagnosis, what I warned the patient could happen if they don’t follow up and they don’t come back. I would also document attempts made by my staff to follow-up by phone with the patient.
If You Don’t Know, Don’t Guess
Many doctors like to think of themselves as authority figures, but there are times (maybe even many!) when, in the best interest of the patient, and to protect yourself legally, you will have to seek help from an OD with more experience in an area you arenot as skilled in, or perhaps you will havetosend the patient to another specialist. Recently, for example, a patient I ran into,who I long ago–and repeatedly–asked to come back to the office for a check-up and new contact lenses, but who nevertheless had been wearing torn contact lenses for months despite suffering recurrent infections, told me hehad developed a white patch on the inside of his eye lid. I reached out to another optometrist who is more skilled than I in the medical model, who informed me of the likely cause and the best treatment. The bottom line: If you don’t know, ask.
Pamela Miller, OD, FAAO, JD, DPNAP, whohas a solo optometric practice based in Highland, Calif., holds a therapeutic license, is California State Board-certified to prescribe eye medications, and offers comprehensive vision care, contact lenses, visual therapy, and low vision services. To contact her: firstname.lastname@example.org