By Melissa Hoercher, OD
June 27, 2018
The news we have to deliver to patients isn’t always good. Eye disease is frightening.
If you learn how to give patients diagnoses in a way that is informative, yet not alarming, you will increase the chances that they follow your treatment plan, return to your practice for care, and purchase the products and services you have prescribed.
When There’s Potential Vision Loss
Anytime we convey potential vision loss, it’s difficult. Patients internalize an emphatic “I’m going blind.” That leap to impending blindness can be turned into a productive conversation if you know how to quickly segue to the prognosis and treatment plan.
My approach: First help the patient understand the threat, and then give them an active role in management. I think the worst thing a practitioner can do is to “doctor speak” and leave the patient without a plan. Reassure that you know your own role, but even more importantly, that you will coach the patient in doing their part to avoid disease progression.
For example, “I know it’s hard to believe that just this eye drop will help you…but research backs me up. The truth is, we’ll never get back what vision you’ve lost to glaucoma, but here’s what I know: The drop you use tonight is your best tool to keep you from losing more vision tomorrow.” Motivate the patient to treat.
In the initial discussion of disease, ask: “Were you aware that this was a problem?” Often, the patient is not aware of visual compromise. This is an opportunity to reassure: “Great. We have a chance to influence this before there is a noticeable impairment.” If the patient had presented cognizant of vision decline, this is your chance to let them know how astute they were to come in when they noticed the problem, and to thank the patient for their confidence in your expertise.
Emphasize Education & Empowerment
Patient education begins with your respecting that the patient is unfamiliar with the requisite complexities of vision. Never is the adage “it’s not what you know, it’s what you do with what you know” more applicable than in patient communication. Tell, then teach.
When a patient with macular degeneration presents, review their retinal photo with an eye model in hand. Be prepared for the blank stare from the patient…or panicked revelations about acquaintances disabled by blindness. A photo of a healthy retina can let them see the compromise in their own retina(s): “Let me help you understand what these ‘changes in the back of your eye’ mean in your case.”
Your patient likely doesn’t know what a macula is. You have to explain this in layman’s terminology: “If I draw a straight line from the center of your pupil, and stop when it lands at the back wall of your eye, I’ve landed on your macula. The macula is where your most detailed vision happens.” Tell.
Ask the patient to look around the room and try not to use their center vision. Further explain: “‘Macula’ is the word for center vision. What you look straight at. ‘Degeneration’ means that something has quit working as well as it used to. So, when I put the word ‘degeneration’ before the word ‘macula’ you can understand that by definition having macular degeneration means you might have a smudge or a shadow right in the middle of what you’re trying to see.” Teach.
Instruct the patient to look around the room again and see if the changes in their eye cause an awareness of a smudge. If so, ask them to “look a little sideways, and see if it goes away, or if you can make things clearer.” Reassure that “practicing looking just off center” may help to fully utilize good vision.
The key is to make the person feel empowered and not despondent. Show the patient just how specifically the retinal camera and OCT can be used to monitor for change. Tell them that you will schedule periodic monitoring in office.
Teach them how to use an Amsler grid. “While I’ll never see through your eyes, here’s something you can use to show me how things look to you.” Amsler can verify whether something is truly different or not. Any change in central vision indicates the need to arrange an unscheduled dilated exam to see what’s going on.
When subjective vision distortion is confirmed in the office, use photos and OCT to show the patient exactly what’s changed. “We can make adjustments in our treatment plan to best move forward in preserving your vision.” Let the patient know that you will involve specialists if their management goes beyond your scope. Address questions and offer an ophthalmology consult if they wish. Give the patient reason to trust your management. Telling them about additional services only supports your willingness to be their advocate.
Tell Them About Low Vision Services
Along with educating patients about their condition, and empowering them to help monitor and respond to changes, make them aware of low-vision services. The words “low vision” can be sobering. Refer sooner rather than later in decline.
You might say: “It’s great that you caught these changes so early. This may be a good time to look into some vision services that go beyond what I can offer here. You’re still very functional visually, but unfortunately, you may not always be as capable as you are now. I work with a group that specializes in helping people best use the vision they have–even if they’re far more impaired than you are.
My hope is that you’ll never need more magnification or specialized training in how to use contrast, but the best time to familiarize yourself with vision devices is while you see well enough to manipulate those. Remember–and you know this–your vision has declined. It may stay like this forever. You may wish at some point, if you become less capable, that someone had given you the option to look into this sooner. What do you think?”
Create a Contract for Care
With the threat of vision loss, a contract for care can spell out responsibilities and ultimately help with patient compliance.
Balance Expertise with Humanity
In closing, remember what a privilege it is that our patients trust us with their vision. Be enough of an expert to know the disease; be enough of a person to know its consequences. Compassion allows the patient to hear what you have to say.
Melissa Hoercher, OD, practices optometry at Mostellar Medical Center in Bayou La Batre, Ala. To contact her: firstname.lastname@example.org