Communication skills

2.1.1

Patient satisfaction is linked to good communication skills

The research literature consistently indicates that patient satisfaction is linked with clinicians having good communication skills: being able to explain diagnoses, prognoses, treatment, and prevention using clear, non-technical terms and being honest, empathic, and able to listen well and address patient concerns. Good communicators are popular with their patients, and good communication skills lead to the majority of your patients returning for future appointments; those patients inform their friends and family so that your patient base increases and you are less likely to be involved in lawsuits.

2.1.2

Why are some patients anxious?

Poor patient satisfaction is linked with preconsultation patient anxiety. A significant number of patients are anxious about attending an optometric examination ^, and particularly fear receiving ‘bad news’ of one form or another. Patients need not display obvious signs of anxiety, and it can be useful to assume all patients have some level of anxiety prior to the examination. Anxiety reduces patient–clinician communication and causes reduced attention, recall of information, and compliance with treatment. This limits the usefulness of the examination because anxious patients are unlikely to provide a full case history and reveal all their visual problems, unlikely to attend appropriately to your instructions, could provide unreliable responses in the subjective refraction, and could easily misinterpret or forget what you said about their diagnoses and management plans. To be empathic, you need to be aware of possible reasons for patient anxiety and these include:

• (a)

  Being told they need glasses. This can be a worry for both prepresbyopic and presbyopic patients who are concerned about the effect on their appearance. ^, Some younger patients report bullying at school because of wearing glasses and elderly patients worry that glasses will make them appear older and more frail.

• (b)

  Fear of vision loss. Particularly true of elderly patients where eye disease is a greater risk. ^, There may also be an associated fear of losing their driving licence because of poor vision.

• (c)

  Cost issues. Both young and old patients are worried about the potential cost of glasses and contact lenses. ^{, ,}

• (d)

  Fear of making a mistake. Young and old patients report worrying about making mistakes during the subjective refraction part of the examination. This may be because they believe that a mistake on their part could lead to the provision of an incorrect refractive correction in their glasses and/or are worried about feeling foolish if they make a mistake.

• (e)

  Fear of increased ametropia. Some patients worry that wearing glasses will make their eyesight worse and that increasing ametropia will mean thicker and less attractive glasses.

• (f)

  Being told that they cannot wear contact lenses any more. Young contact lens wearers typically report a better vision-related quality of life than glasses wearers and some may worry about being told that they cannot wear contact lenses any more.

• (g)

  Adaptation problems. Many older patients report concerns about being able to adapt to their new glasses.

• (h)

  Fear of looking foolish. Some patients are very tentative about admitting some of their concerns about their vision in case they are made to look foolish by raising the issue. Concerns about vitreous floaters are a typical example of this.

• (i)

  Fear of mental health problems. Charles Bonnet syndrome, in which patients suffer visual hallucinations, is not uncommon in patients with visual impairment, particularly if severe, and patients are worried that they may be developing dementia or other mental health problems.

2.1.3

Building a rapport: Relaxing the patient

The entire patient visit needs to be considered as otherwise the ‘arrive–wait–prescreen–wait’ process could add to patient anxiety prior to meeting the optometrist, particularly given the silence about data collected in prescreening. Good communication skills from reception staff and clinical assistants are hugely important to help relax the patient.

• (a)

  Provide information about the eye examination (via websites, leaflets, pamphlets, and so forth) prior to the appointment because this can reduce anxiety and improve satisfaction with the consultation.

• (b)

  Provide a comfortable and welcoming setting in the practice waiting room. Comfortable chairs, a selection of magazines, some low level music, and so forth can all help to relax the patient. Framed copies of the qualifications of all staff, either in the waiting room or the examination room, can provide reassurance to some patients.

• (c)

  Clinical assistants should fully explain the tests that they are performing and indicate that the test results will be discussed with them by the optometrist.

  • A good communicator will be able to relax an anxious patient and increase patient satisfaction with the eye examination. ^, There are many ways to relax a patient and build a rapport and these include:

• (d)

  It would appear that formal attire is becoming less important than it once was. Research from medicine suggests that although some older patients prefer a formal, ‘professional’ appearance, there is a wide variation depending on country, setting, and context of care.

• (e)

  First impressions count and some clinicians like to greet patients by name and escort them to the examination room. Smile and make eye contact.

• (f)

  Change the chair height to ensure you are at the same eye level as the patient.

• (g)

  At the start of the case history, pay full attention to your patient and do not look at the screen (or put your pen down). Your posture and style should be relaxed but attentive.

• (h)

  Some clinicians like to chat about non-clinical issues (e.g., weather, holidays, sports teams, parking) prior to the examination to help relax the patient. In this respect, it can be useful to make a note of any relevant information (e.g., a child’s favourite sport, sports player, team, author; the patient’s pets and their names, their children’s successes) to allow you to start a conversation at subsequent visits.

• (i)

  Maintain regular eye contact and use the patient’s name at appropriate intervals during the eye examination. The preference for the use of the patient’s first or family name can be linked with their age and it can be useful to ask which your patient prefers. Your tone of voice and intonation should match what you are saying.

• (j)

  An open question is typically used to start the case history ( section 2.3.1 , step 3) as this allows patients to tell you about any problems with their vision or glasses. A balance is required between allowing patients plenty of time to discuss their problems and not rushing them, but at the same time retaining control of the discussion. You need to ensure that patients feel that you have fully listened and understood their problems and you may even need to allow them to talk about information that you know is not necessary from a diagnostic viewpoint. However, you also need to develop the skill of being able to interrupt an overly talkative patient without appearing rude.

• (k)

  Some patients are very shy, and an open question provides little information and may make the patient feel uncomfortable. Closed questions (i.e., that have a yes or no answer, such as “do you have any problems seeing the whiteboard at school?”) can be useful at the beginning of the case history with such patients. An open question can be used later in the case history if the patient relaxes and conversation becomes easier.

• (l)

  Listening is a hugely important communication skill. It is vital that you have fully listened to the patient and understood his or her problems. There are a variety of cues to indicate to the patient that you are listening, and these include maintaining eye contact and demonstrating attention by nodding and/or using affirmative comments such as “I see,” “I understand,” “OK,” and “go on,”. Listening is also indicated by using follow-up questions to comments, such as asking about the location, onset, frequency, and so forth of headaches when the patient indicates suffering with them. Finally, summarising the patient’s problems at the end of the case history (see section 2.3.1 , step 10) is a useful way of indicating to patients that you have listened to what they have to say and fully understand what problems they are having, and it also provides the patient with an opportunity to inform you if you have missed anything.

• (m)

  Provide a brief explanation to the patient of each test that you use during the eye examination. Patient knowledge about the contents of an eye examination is poor, ^, and patients indicate they want to be better informed. Suggested information, in lay terms, is provided for each test described in later chapters.

2.1.4

How to improve your communication skills

All students should gain adequate communication skills via lectures, reading, and clinic feedback. How do you become a better communicator? A helpful quality about communication skills is that you can learn them anywhere and from anybody. Obviously observing an optometrist or another health professional who is popular with patients could be particularly beneficial. You can also learn by experience so that any summer job that involves working with the general public can be valuable. Indeed, it is obvious from the level of communication skills shown in clinics, which students have had jobs that involved working with the general public and which ones have not. Finally, recording yourself performing a case history and/or eye examination can be a valuable tool and will particularly highlight your non-verbal communication skills. Review the recording with a colleague and critique your non-verbal communications skills. Try to avoid negative non-verbal communication cues such as a blank, unresponsive face, minimal eye contact, long silences, none or few affirmative gestures, inattentive or anxious gestures such as touching your face/hair or twirling a pen, leaning backwards, using a closed body position (arm across your body, legs crossed) or a dull, quiet tone of voice with no intonation.

2.2.1

Electronic health records

A large and increasing number of optometric records are now computer-based and avoid the problem of illegible handwritten records and should reduce the likelihood of lost records (assuming appropriate backup arrangements), which were a significant problem with card-based systems. Other advantages of electronic records over card-based systems include that information from a previous record can be uploaded and then amended with information from the current examination (this can also be done for the right and left eyes); they can be linked to digital ocular photographs, and referral letters are easier to produce and print. Electronic health records vary widely and will continue to improve, but current disadvantages of many systems include the inability to sketch various features (e.g., cataract and fluorescein staining patterns) if digital photography of both the external and internal eye is not available; getting used to different systems can be difficult for locum optometrists; going to a complete computer system means that some companies scan old paper records which can become more illegible by that process; copying information from previous records or the other eye can lead to information overload and/or that you forget to put in details; drop-down lists can become very long and it can be difficult to get an overall picture of a patient because of the fragmented nature of the information. The latter can mean it is difficult to highlight important details as with a paper record card where you can write it in large capitals/highlighter on the front page.

2.3.1

The most basic case history

The case history of a patient who does not wear glasses or CLs and has no oculo-visual problems is described first because it is the simplest case history to perform. This section describes what questions you should ask (in lay terms), in what order and how to record the answers (an example of recording a basic case history is given in section 2.3.8 a): It can be useful to master this case history first, before building on it with more complicated case histories described in subsequent sections.

• 1.

  Welcome the patient and introduce yourself.

• 2.

  Sit about 1 m from the patient at eye level. Your posture and style should be relaxed but attentive. Lean slightly forward toward the patient. Try to avoid long silences while writing notes and learn to type or write down answers in abbreviated form ( Table 2.1 ) as the patient is talking, while retaining intermittent eye contact.

  Table 2.1

  Abbreviations that could be used during the recording of a case history

  Abbreviation	Stands for	Abbreviation	Stands for
  CC (or PC or RFV)	Chief complaint or presenting complaint or reason for visit	Sxs	Symptoms
  c/u (or C/U)	Check up	Px (or Pt)	Patient
  F/U	Follow-up appointment	Hx	History
  DV	Distance vision	LEE	Last eye examination
  NV	Near vision	OH	Ocular history
  OK	Okay	FOH	Family ocular history
  ↑	Increase	cat	Cataract
  ↓	Decrease	AMD/ARMD	Age-related macular degeneration
  (or c )	With	POAG	Primary open-angle glaucoma
  (or s )	Without	GH	General health
  Rx	Prescription/glasses	FMH	Family medical history
  CLs	Contact lenses	HBP	High blood pressure
  RE (or OD)	Right eye	DM	Diabetes mellitus
  LE (or OS)	Left eye	CVA	Cerebrovascular accident
  B (or binoc)	Binocular	meds	Medication
  BE (or OU)	Both eyes	Ung.	Ointment
  1/7, 3/7	1 day, 3 days	o.d.	Once daily
  1/52, 3/52	1 week, 3 weeks	b.i.d. (or b.d.)	Twice a day
  1/12, 3/12	1 month, 3 months	t.i.d.	Three times a day
  HA (or H/A)	Headaches	q.i.d.	Four times a day
  Dip	Diplopia	p.r.n.	When needed
  H	Horizontal	q.h.	Every hour
  V	Vertical
  Fl & Fl	Flashes and floaters	LME	Last medical examination

  A tick (✓) used to be used to indicate ‘OK’, ‘good’, or ‘fine’, but has been fallen out of favour owing to its misuse in other parts of the record card.

• 3.

  Chief complaint (CC) or reason for visit (RFV): Determine the CC by asking an open-ended question such as “Are you having any problems with your vision or your eyes?” In this example, the patient reports no vision or eye problems and has just attended for a routine eye examination.

• 4.

  Glasses/CLs. Ask “Do you wear glasses or contact lenses at all?” In this scenario, the answer is no, so ask whether the patient has ever worn glasses or CLs.

• 5.

  Last eye exam (LEE). Ask the patient when and where was their LEE. Ask if the optometrist reported any problems at that time.

• 6.

  Visual demands. Ask about the patient’s distance and near vision and tailor the question to the patient’s vocation and/or hobbies. For example, “How is your distance vision?” “What are the visual demands of your job?” “Can you see the white board at school?” “How about the TV?” “Do you drive?” “How is your vision for driving?”

  • “How is your near vision?” “Is reading OK?” “Can you see your music sheets when playing the piano?” For presbyopic patients, you need to discover the distance used for computer use, reading, and other near tasks such as sewing, reading music, and so forth and the use of any additional reading lights (e.g., angle-poise or goose-neck lights; see section 3.2 ).

  • It can be particularly useful to ask patients about contact sports (football, rugby, hockey), swimming, fishing, and racquet sports and whether ametropic patients wear their glasses or contact lenses for these sports and activities, so that they can be advised appropriately (see section 2.4.2 ).

• 7.

  Symptoms. Ask about the most prevalent oculo-visual symptoms. “Do you suffer from headaches?” “Any double vision?” “Any eyestrain?” “Any pain or discomfort in the eyes?” “Do you see flashing lights and floaters?”

• 8.

  Ocular history (OH), family ocular history (FOH):

  • (a)

    OH: Ask an open question: “Have you ever had any problems with your eyes at all?” then more specifically: “Have you ever been to the doctor or hospital about your eyes?”

  • (b)

    FOH: Ask an open question such as “Do any eye problems or eye diseases run in the family?” This can be clarified by providing examples of common hereditary conditions (in lay terminology) for their age, gender, and race, if pertinent. For example, for children and young adults ask “Any short-sightedness? . . Squint? . . . Lazy eyes? . . . any colour vision problems?”; for African American, African Caribbean patients over 30 years of age and all other patients over 40, ask about any family history of glaucoma; for patients over 60 ask about any family history of cataract, age-related maculopathy, and glaucoma. Do not ask about specific conditions (e.g., myopia) if you know the patient already has the condition.

  • (c)

    If a patient reports that he or she is adopted, make sure you record this and do not ask about family history at future appointments.

• 9.

  General health information.

  • (a)

    Ask “How is your general health?” and add a follow-up question such as “... any high blood pressure or diabetes?” If you receive a positive response, ask the patient how long he or she has had the condition because ocular effects of systemic diseases are more likely the longer the patient has had the condition. For example, the duration of diabetes is a major risk factor for vascular complications of diabetes, including diabetic retinopathy. If the patient has diabetes or hypertension, ask how well the condition is controlled. The risk of diabetic retinopathy is greatly reduced with good glycaemic control in diabetic patients and by good blood pressure control in a patient with diabetes and hypertension.

  • (b)

    Ask “Do you take any medications?” It is important to ask this even if patients say that their general health is good because some patients believe their general health is fine when it is controlled by medication. Patients may also be taking medications, but are unsure why because the medical diagnosis was not properly explained or was poorly understood. Note that some drugs can have adverse ocular effects, such as beta-blockers (dry eyes) and oral corticosteroids (posterior subcapsular cataracts). If you receive a positive response, ask the patient the number and dosage of the drug and how long the patient has been taking it because this will influence the likelihood of adverse effects. Note that patients may not consider ‘over-the-counter’ tablets (including travel sickness pills, antihistamines, sleeping pills, and painkillers), inhalers, or eyedrops as medications, so it can be useful to ask about them specifically, particularly with patients with unexplained symptoms. Similarly, female patients may not consider birth control pills to be medication, yet the drugs in these pills can have adverse ocular effects.

  • (c)

    Ask whether the patient has any allergies.

  • (d)

    Family medical history (FMH): Ask an open question, clarified by examples, such as ‘Has anybody in your family had any medical problem?’ This can be clarified by providing examples of common hereditary conditions such as ‘any diabetes or high blood pressure in the family?’

  • (e)

    Last medical examination (LME): Ask the patient when was your last visit to a physician and obtain the name of the physician.

• 10.

  Summary: Summarise the pertinent information from the case history and allow the patient to clarify any misunderstanding on your part or to add any additional information that has been missed. For example, “So, Mr. Hazard, you are having no problems with your vision or your eyes and you are just here for a routine eye examination, is that correct? Are there any issues that I’ve missed?”

2.3.2

Case history for a patient with glasses and contact lenses but without visual problems

This builds upon the basic case history described in 2.3.1 . However, at step 4, the patient indicates that they wear glasses and/or contact lenses. Step 4 is now as follows (an example of the recording is given in section 2.3.8 b):

• (4a)

  If the patient wears glasses (ask if you are unsure), you need a complete description of them.

  • (i)

    “When do you wear your glasses?”

  • (ii)

    “How is your distance vision in your glasses?” followed up by “Do you feel it is as good as it was when you first got them?” This can be adapted to suit the patient. For example, a student could be asked “Any problems reading from the whiteboard?” and “Is everything clear on the TV?”

  • (iii)

    “Any problems with reading with the glasses?”

  • (iv)

    “How is your distance/near vision without your glasses?”

  • (v)

    “How old are your glasses?”

  • (vi)

    “How many pairs of glasses do you have?”

  • (vii)

    “Where did you get these glasses?”

  • (viii)

    “How old were you when you first wore glasses?”

  • (ix)

    “Do you have prescription sunglasses?”

• (4b)

  If you are unsure, ask if the patient wears contact lenses. If the patient does wear lenses, even if only occasionally, then you need a complete description of them.

  • (i)

    “What type of lens are they?” (e.g., soft, gas-permeable, toric, multifocal, and brand if known)

  • (ii)

    If relevant (i.e., not single use lenses): “How old are your current lenses?” “How often do you replace your lenses?” and “What care solutions do you use?”

  • (iii)

    “How long do you usually wear the lenses each day?” and “How many days per week?” The first question can be confirmed by asking when the lenses are typically inserted and when they are removed, because average wearing times are typically underestimated.

  • (v)

    “How is your vision with contact lenses and how does it compare with the vision you get with your glasses?” If the patient wears both glasses and contact lenses, you will have to ask about visual symptoms (i.e., distance blur, near blur, headaches, eyestrain) for both forms of correction.

  • (vi)

    “Are you currently having any problems with your contact lenses?”

  • (vii)

    “When was your last contact lens aftercare and when is your next aftercare check scheduled?”

2.3.3