STRATEGIC SKILL BUILDERS: Continuing Education 
COMPLIANCE
Shorter Contact Lens Replacement Schedules: Getting Patients to Comply
Short wearing schedules are best, but enforcing them takes finesse.
By Gary Gerber, O.D., Hawthorne, N.J.

We've all had patients become confused when we ask "Which is better, one or two . . . three or four?" Now, it's payback time for us. Imagine a patient asking, "Doctor, tell me -- which is better . . . ?" No, I'm not talking about the difference between two lenses in your phoropter. I'm referring to your patients' contact lens wearing schedules. Is 1 week better than 2? Is 1 day better than 30? As more lenses and modalities become available, we may become as confused as our patients.

Since 1995, about a dozen new soft contact lenses have been introduced. We've started to fit disposable lenses with schedules as short as 1 day and as long as 30 days. Some of us now question the very word "disposable." Isn't it true that "1-day," "2-week" and "30-day" lenses are all "disposable?" If we're confused, our patients surely are.

Here, I'll explain why I believe shorter wearing schedules -- especially daily ones -- are better, and how to make your patients comply.

WHY SHORTER IS BETTER

The foundation for building better patient compliance is built upon simplifying the choices. Find the modality you believe works best and recommend it whenever clinically appropriate. I like shorter schedules because:

• They benefit eye health. Clinical studies show this. Usually, fewer solutions are needed to care for lenses. Fewer bottles and steps mean less chance of patient mistakes with lens care. Fewer solutions also mean less chance for adverse reactions and sensitivities. Also, if lenses are worn less often, there's less chance of problems related to protein and lipid buildup, such as giant papillary conjunctivitis.

• Your bottom line benefits. Compliant patients deplete their contact lens supplies quickly, which makes them come in for appointments more often. This allows you to monitor their eye health more often, and consequently helps boost your bottom line.
  Most of us would agree that patients are less likely to return and incur professional fees when they still have an ample supply of contact lenses. Shorter wearing schedules (more frequent disposal of lenses) mean that over a patient's lifetime you'll have more opportunities for comprehensive well-eye health visits -- "yearly eye examinations." If you graph your patients' recall return rate against their wearing schedules, you'll find that they return sooner when they throw their lenses away more often.

• Patients are more compliant. My own experience shows this. Both patients who are entirely new to wearing contact lenses and experienced patients who are new only to a given lens are generally compliant at first. As time goes by, they become less compliant. If you fit them with shorter-wear lenses, this compliance drop-off happens too, but not nearly as badly. And if you fit patients with daily disposable lenses, it's even less of a problem. But there's almost always room for improvement, as I'll discuss now.

BOOSTING COMPLIANCE

Here are some approaches to boosting the compliance of your more stubborn patients.

• Project confidence. My experience as a practice-building consultant has led me to classify optometrists' personalities and practices into two main groups:

  • Doctors who genuinely believe that what they do and how they do it makes a difference in their patients' lives. These doctors are independent thinkers and are willing to challenge "business as usual" not only when it comes to how they run their practices, but also with regard to clinical procedures and how products are prescribed. They're leading-edge practitioners who continually reinvest in their practices.

  • Doctors who "go with the flow" are the opposite. They're as clinically competent as the first group but will perform a test because "that's how I was taught and that's how I've always done it." They're followers, not leaders.

I've observed that the first group is more likely to embrace new contact lens modalities. Accordingly, they've adapted shorter disposable lens cycles to their contact lens arsenal first. These doctors don't just believe that shorter is better. They know it -- and so do their patients. Their practices are high-tech, clean and patient friendly.
The aura of professionalism is projected within every segment of the office. The way the office looks, the way the staff behaves -- the entire optometric "gestalt" tells patients, "We're up to date and we know what we're doing." These doctors have more compliant patients because their offices are set up with their progressive philosophy in mind. When they tell their patients to wear lenses for 1 day and then throw them away, their patients are apt to comply.
These two personality types show us that compliance needn't be "enforced" or "policed." A professional, credible optometric experience alone does more than anything else to bolster compliance.

• "Assumptive selling." When you go to your physician for treatment, he doesn't ask whether you'd like to get better in 1 day or 2 weeks. He assumes you want to get better as fast as possible, so he treats you with the regimen he believes is best. While he may not recognize it, he's using a technique called "assumptive selling," meaning he assumes you want the best and are willing to pay for it. With this in mind, he isn't really "selling" at all. He's giving you something he thinks you already want.
  Treat your contact lens patients the same way. When discussing lens modalities with them, assume they want the best. In this sample script, let's use daily disposables as an example and see how assumptive selling differs from other methods.
  Doctor One: "Mr. Myope, you can wear contact lenses that you throw away every 3 months, every 2 weeks or once a day. The daily disposable lenses are more expensive. Which lenses would you like?"
  Doctor Two: "Mr. Myope, I'm going to fit you with a very healthy lens called a daily disposable contact lens. Let me go get a pair."
  Doctor Two assumes the patient wants the lenses. This makes his statement to the patient short, direct and to the point. He immediately and succinctly states his confidence in the chosen modality and takes control of the situation. His patient is sure to catch his confidence and enthusiasm for the lenses. This translates to a better doctor-patient relationship built on the doctor's belief in and knowledge of the lenses he's prescribing. Ultimately, this will lead to better patient compliance.
  Contrast this with Doctor One. While his patient may be fit with the same lenses, this doctor shows no conviction regarding the lens's benefits. His only reference to daily disposables is the price! He asks the patient to choose the lenses he'd like instead of offering a firm, knowledgeable recommendation.
  His patient might not get the same sense of professional confidence as Doctor Two's patient. This could easily lead to poor compliance. The patient may think, "If there's no difference between the lenses (the doctor would've told me if there were), then it won't matter if I stretch my wearing schedule. Contact lenses aren't that big a deal."

•  Reinforce the habit. Given the complexities and schedules of modern life, it isn't surprising patients forget to change their lenses when they should. One could argue it's remarkable they ever get it right.
  However, most of these patients probably remember to do things like brush their teeth every day. Why do they remember this and not their lens schedules?
  One reason is their own sense of how important the task is. As we discussed, your degree of conviction has a direct effect on the importance your patient gives to contact lenses and their schedules.
  The second reason is habit. The patient's used to brushing his teeth, dropping his children off at school, etc. So it's critical that you regard compliance as a habit and devise ways of helping your patients form the habit. Try these steps:

  • When fitting patients who are new to shorter-term lenses, let them see you throw a lens away. Let them know that it's okay to toss a lens in the garbage. I've even jokingly told new wearers, "If you really want to have some fun tonight, tear the lens in half and flush it down the toilet!"

  • Contact patients the next day to see how they're doing. Go beyond "how are you seeing and how do your lenses feel," and also ask, "what was it like to throw your lenses away?"

  • See patients 2 days after you first fit them. Historically, many of us see contact lens patients for their first follow-up visit at 1 week, but I feel this is way too long to wait. Two days after the first fit, once again remove the patient's lenses and throw them away in front of him. Follow up again in a day or two (a short e-mail note is great for this) and reinforce the new habit!

  • Load the pantry. It makes sense to dispense as many contact lenses as possible at the patient's yearly examination because so-called "pantry loading" helps bolster compliance. Patients (and consumers in general) are more likely to use up the products sitting on their shelves when they have a large quantity of those products. For any disposable lens time period, patients will see more single-use disposable lenses than quarterly replacement lenses sitting on their medicine cabinet.

• Nag 'em. For most of our patients, getting an eye examination is at best an annual event. Getting fit with contact lenses is usually a once per lifetime event. That means that shortly after the lens is fit, the novelty wears off.
  Therefore, it's incumbent upon you to continually keep in contact with your patients. All of your external marketing -- from tag lines on bills to your phone's on-hold message -- should reinforce your conviction that compliance is important. Continually communicate with your patients via mail, e-mail and Web page newsletters. Keep stressing the importance of compliance. Patients need to hear and see this message repeatedly, and they need to hear it and see it from you.

• Program for compliance. No doubt, when a contact lens patient returns for follow-up, your paper form or computer software record has a place to record your findings. Yet most O.D.s don't have a place on that form to remind them to ask patients if they've been compliant.
  Structure your examination records so that this question, as well as questions about solution usage, if any, become part of your routine. Once this task becomes a part of your process, you can delegate it to your staff. For example, staff can use a sheet that has a check-off box next to each of the following points:

  • History/chief complaint

  • Visual acuity

  • Average wearing time

  • Wearing time today

  • Compliance

  • Solution.

Building these questions into your testing sequence and delegating them to your staff further enforces the notion that good compliance is a part of "business as usual."

IF AT FIRST YOU DON'T SUCCEED . . .

If you still have patients who might not be getting your message, try these pointers:

• Be kind, not cruel. Discuss compliance again at check-ups later on in the year. Offer to fit the patient whose compliance seems to be slipping with a lens that better meets the schedule he's adopted. For example, if you find that a patient to whom you dispensed 2-week lenses is wearing them for a month, tell him that he should be wearing 1-month lenses instead.
  Say something such as, "Since you're not getting the full benefit of your 2-week lenses, let's change to a 1-month lens."
  If you say this positively and as a patient advocate, most patients will opt to stay with the 2-week lenses they already have.
  If you instead admonish and scold the patient for wearing his lenses too long, he might ask you about lenses he can wear longer than 2 weeks. You haven't left him any alternative but to agree that he made a mistake and can't responsibly handle the 2-week wearing schedule. You've not only lost control of the situation, but you have a patient who's likely to wind up in a lens with a longer wearing schedule. And, as we noted, that's usually not good for the patient or the practice.
  One compliance reinforcement technique I'd never use is quite popular, even though it rarely works. That's to "scare" patients into compliance. Many O.D.s show patients graphic images of diseased corneas and tell them, in effect, "This is what will happen if you don't throw your lenses away when I say to."
  If you find yourself continually telling your patients this, realize that it's not working. If you want to scare your patients into complying, do it by taking away the emotional reward their contact lenses offer.
  Get at the real reasons patients chose to wear contact lenses in the first place -- the freedom, self confidence and self assuredness they didn't get with their glasses. Let them know that should their noncompliance continue, they'll lose the benefits that drew them to contact lenses in the first place. Patients can't relate to pictures of giant papillary conjunctivitis, but they can relate to wearing glasses while playing tennis.

• Don't go it alone. Enlist the help of your staff with all you do. Once they understand the importance of good compliance, let them help you spread the gospel. They have many opportunities to remind patients in a friendly, concerned, non-confrontational way. Here are a few examples:

  • The telephone. When Mrs. Jones, a daily disposable lens wearer, calls to order lenses, staffers should check when lenses were last ordered and how many. This will alert you to compliance or lack of it. If the patient is on schedule, have the staffer congratulate her. If there's a problem, the staffer should politely remind her of the benefits of lens wear --without scolding. Here's a sample script:
    Staffer: "Mrs. Jones, I notice you ordered a 3-month supply of lenses 4 months ago. Is everything okay?"
    Mrs. Jones: "It's fine. I just wore a few pairs more than once."
    Staffer: "When you stretch your wearing schedule like that, you're missing out on the main reason for getting daily lenses in the first place -- the health, safety, convenience, comfort and great vision."

  • Pretesting. During this part of a patient's exam, your contact lens technician should again review the correct lens schedule. She should acknowledge good compliers and have a frank, but friendly, discussion with non-compliers.
    Role-play some of these scenarios during staff meetings to get staff comfortable with the direction in which the conversation should go. Scripts aren't necessary. If you've done your job of educating your staff about the importance of good compliance, the role playing should come naturally, with genuine concern for the patient as the underlying message. Focus on concepts and emotions, not exact words.

IT'S WORTH THE EFFORT

There's little, if any, expense involved in boosting your patient's compliance. Now let's see how only a slight increase in compliance can impact your practice.

Say you have 500 patients wearing "2-week" lenses with a typical wearing schedule of 3 weeks. If you convert only half of these patients to the proper 2-week schedule using the tips I've recommended, you'll examine 250 patients sooner instead of later. In fact, if you have a 1-year recall program in place, they'll come in about 4 months sooner!

Now, if you collect a $100 professional fee from each of these patients, you'll have the time value of money on your side for a full 4 months.

Add to this additional income from product revenues, and you've just enhanced your practice's bottom line while safeguarding your patients' eye health and their sense of well-being. 

References available upon request.

Dr. Gerber is president of The Power Practice, a company specializing in practice building solutions for optometrists -- consulting, seminars, video programs and software. You can reach him at DrGerber@PowerPractice.com or 800-867-9303.