STRATEGIC SKILL BUILDERS: Continuing Education
COMPLIANCE
Encouraging Patients to Understand the Rationale for Routine Examination
How to keep them coming back.
By Donna Higgins, O.D., Prairie du Chien, Wis.

To maintain a successful practice, you have to keep patients coming back. A part of providing the best care to our patients is making sure they follow up with whatever routine care is necessary. This requires techniques that encourage patients to understand the rationale behind recommended routine examination. Following are some techniques that have worked well in my practice.

NO "CANNED" SPEECHES

It's essential that patients know there's a valid reason why you want them to return for a routine exam. You need to make them see that returning is in their own best interests. A convenient way to present this is to include it in your discussion with each patient at the end of his exam.

One "canned" speech won't work for all patients. Every patient is different, and the reason why routine examination is important will be different for everyone, as follows:

• For example, perhaps you've just examined a child. There's no need for a spectacle correction or any other treatment now, but you see potential for problems in the future. You might say to the parent, "He doesn't need glasses now, but I think there's a good chance he'll become nearsighted sometime in the next couple of years. Here are the things to watch for . ."

• People commonly think the only reason to see an optometrist is for new glasses. A simple explanation of the need for return for these patients might be, "It would be a good idea to come in once a year for exams. It's not the glasses part of the exam that's so important -- it's all the other things we do to monitor the health of your eyes."

• Many people genuinely don't understand that visual anomalies and ocular disease can be present before noticeable symptoms arise. Glaucoma is the prime example. Tell patients, "Glaucoma usually has no noticeable symptoms for you until it's way too late. The only way we can watch you for glaucoma is if you come in once a year and let us do all the tests."

• For an elderly patient who hasn't been good about routine exams, you could say, "So many things can happen to your eyes as you get older. Many times we can make a big difference by catching changes in time. We need to see you more often to be able to do that."

Whenever we finish examining a patient, we have reasons for deciding when he should be recalled. We know what we'll be watching for. Don't assume your patient knows this, too, without an explanation. You have valid reasons for recommending routine examination, reasons that are in the patient's best interest. It's simple enough to share those reasons with him.

"BUT I DON'T LIKE TO GO TO THE DOCTOR!"

Many people go to a doctor only when absolutely necessary because they find doctor visits frightening or otherwise uncomfortable and unpleasant. Anything you can do to make your office, and the patient's experience there, pleasant and comfortable will encourage more people to return for a routine exam. The following are examples of simple things that can make a difference:

• the decor of your office

• a waiting room set up so that people can face each other and chat to make waiting more tolerable

• a play table for children keeps kids occupied, providing a more pleasant environment for them and everyone else.

Other, more complex ways to make patients comfortable include:

• A friendly and personable staff. This can go a long way toward making patients comfortable. Patients greeted by name and with a friendly "hello" will get the message immediately that they're in a safe, friendly environment.

• Helpful staffers. Anything your staff can do to make things easier for patients will encourage more of them to comply with recall. For example, make sure someone assists elderly and handicapped patients with the door. Having someone at the reception desk who's knowledgeable and able to explain insurance benefits also helps.

• Staying on schedule. Waiting is probably the number-one thing people dread in a doctor's office. Always staying on schedule is, of course, the best answer. When this isn't possible, anything that makes the patient's wait more pleasant and wastes less time is helpful. If you're behind schedule, frame selection can be done before the exam rather than after. Current magazines in the waiting room and a receptionist who's a pleasant conversationalist can make waiting more tolerable.

• A genuine, humane attitude. Your own attitude and demeanor are vital in dealing effectively with reluctant patients who are really just frightened. It's possible to come across as knowledgeable, capable and reliable without being intimidating. Patients are real people and are most comfortable when given the respect they're due. You're also a real person. Frightened patients, in particular, will respond best to a doctor who reveals that real person in themselves and who genuinely recognizes the patient as an equal human being.

• Expressing empathy. When patients require routine testing that's unavoidably unpleasant, an expression of empathy tells them there are good reasons for putting up with the unpleasantness. Try saying, "I know it's expensive and an aggravation to have dilation and field tests every year, only to have me tell you everything's fine and you don't have glaucoma. I wouldn't put you through it if I didn't think we had to watch this closely and catch it early if you do develop glaucoma."

We all see patients who have serious ocular disease and may have legitimate reasons to be frightened of routine doctor's visits. The way to handle this is to make it clear that you are this patient's strong ally in dealing with the situation. The patient has a reason to come in that goes beyond monitoring a frightening condition; they will be seeing someone who will help them through the scary situation.

SCARED AWAY

An issue related to fear associated with a doctor's office is what to do with the non-compliant patient. Intentionally frightening a patient in an attempt to force compliance (for example, showing a non-compliant contact lens patient a gory picture of a corneal ulcer) can often result in the opposite effect from what you want. Most of us lose trust in someone who does hurtful things to us. A doctor who intentionally frightens -- or worse, gets angry and scolds a non-compliant patient -- is probably going to lose that patient's trust. It's not likely someone will heed the advice of a doctor he doesn't trust.

A second risk of frightening a patient is the possibility of inducing an even deeper non-compliant attitude. Many people avoid doctors because they don't want to find out there's something wrong. Intentionally frightening someone is like saying, "You have to come in every year so I can tell you about all the horrible things that are wrong with your eyes." There's not much incentive in seeing a doctor annually if it means new worries and anxiety.

A better approach is to maintain an attitude of concern that your patient must not understand the risks he's taking by not coming in as often as advised. You might still describe the possible adverse consequences. You might even show a patient a gory picture of a corneal ulcer or tell him a horror story about diabetic retinopathy that wasn't caught soon enough.

If you present a patient with the frightening consequences of non-compliance, you must present them as a means of educating him about the bad things that really can happen. It has to be clear that you're not trying to frighten him; you're trying to prevent all these consequences. The patient must understand that routine examination is a way to avoid the scary things. What you're offering him is a way to feel and be safer, not more frightened.

Give the patient a polite reminder that he has responsibilities for his own health. For example, for a diabetic patient who hasn't been good about annual exam, you might say:

"These are all the things that can happen to your eyes when you have diabetes. I'm trying to keep them from happening, but I need your help. I need you to come in once a year so we can watch for all this."

"BUT DOCTOR, IT COSTS TOO MUCH!"

A frustration most of us have probably faced is patients who don't want to spend on health care. Patients who don't maintain a routine examination schedule for financial reasons have to be convinced that their money will be well spent. Here are some ways to accomplish that:

• Many patients don't realize that medical insurance will often cover medically related expenses at the optometrist's office; they don't have to have "eye insurance." Having your receptionist routinely ask about medical insurance coverage when the patient is initially processed is a good way to make people aware of this, as well as making them aware that we do more than "sell glasses."
  With Medicare patients, simply recommending they "take advantage of their Medicare coverage and come in once a year" is often enough to make people realize they can take care of themselves better and it's not going to cost much.

• Many people think that entering an optometrist's office means they're going to have to buy a new pair of glasses. A simple, forthright explanation is often all that's re-quired: "I never tell anyone they need new glasses unless they really do. I want to see you every year to make sure your eyes stay healthy. We'll never make you buy glasses you don't want or need."

• For some people, routine examination can be presented as a much more cost-effective option. With a non-compliant contact lens patient, say, "So many problems can arise with contact lenses that are much easier to solve if we catch them early. It will cost you less to just come in once a year instead of waiting till you end up with those more complicated problems."

• For a glaucoma suspect, say, "Even if it's expensive to have all this testing every year, it will pay you back a thousand-fold if you ever do develop glaucoma and we catch it early."

EXPLANATION, PLEASE

Patients who have some understanding about what's going on with their eyes are more likely to comply with routine examination recommendations. A basic understanding is essential for patients with ocular disease that requires monitoring. The challenge is getting the patient to listen to and understand your explanations. Try these techniques:

• Use plain language. We'd all like to believe that our patients hang on our every word with rapt attention. The reality is, we're probably lucky if they hear, let alone understand, even a fraction of what we say. To have any hope of getting an explanation across, that explanation has to be in understandable terms and it has to be concise. Many concepts and terms are second nature to all of us but Greek to the average person. Explanations have to use words and descriptions that an average person can understand. This isn't a matter of "talking down" to a patient -- it's a matter of translating into plain English.
  Think about what you didn't know before you went to college. Maybe you knew the words, "iris, cornea, retina," but did you really know which was which? Your patient probably doesn't. Learn to describe things clearly by trying your explanations on friends, family members or someone who will tell you if they don't understand.

• Keep it brief and to the point. Most patients want some understanding of their condition, but a long, overly detailed explanation will make them "tune out" and stop listening. The brief explanation will communicate more information. Think about what facts are essential for your patient to know and explain only those. Find ways to keep your explanations brief while still getting essential points across.

• Try a multisensory approach. Most people retain and understand information best if it's presented in auditory and visual modes at the same time. For a multisensory explanation, show an eye model, drawing or photo while you explain something. If you follow-up this information with a written handout the patient can take home and read, you've presented the information in a third way and provided the reinforcement of repetition.

REPEAT, REPEAT, REPEAT

Repetition reinforces and will increase compliance with and understanding of your re-examination recommendations. Here, staff involvement is more effective than your own. Keep these points in mind:

• If a patient returns to the office several days after examination to pick up a new spectacle correction, have the staff member who's doing the dispensing briefly repeat the follow-up recommendation: "I see the Doctor wrote in your file that she wants to see you again in a year because of your cataracts. We'll send you a reminder when it's time to come back."

• If a patient comes back to the office at any time throughout the year, perhaps for a frame adjustment or repair, have the staff routinely pull the file to check when that patient's due again for recall. This is an opportunity to give the patient another reminder that routine examination is important and expected:

  • "Looks like we'll be seeing you again in March. That's when you're due to come back for an exam."

  • If the patient is overdue for re-examination, the staff can urge him to schedule an appointment right there on the spot.

• Explanation is effectively reinforced with patient handouts or brochures explaining visual or ocular conditions. Handouts you've written yourself tend to be more effective than commercial versions because they use the same language and descriptions you've already used verbally. Just as with verbal explanations, patient handouts should use simple language and be concise. Written explanation that contains drawings will be more effective.

• The importance of routine examination is best reinforced for some patients by a reminder that they don't have to wait for a recall card to come back in. "I need to see you again in 1 year. If you think anything's wrong with your eyes before then, you can come in any time." This encourages people to understand the 1-year recall is important, expected and reasonable. It also reminds them that eyes that are problem-free won't necessarily remain that way.

• When a patient's been compliant about routine examination, complimenting him is an effective way to reinforce the importance of routine care. Say, "I'm so glad you brought your son in when he is still so young. You saved him a great deal of trouble in school by catching this problem early." Or try, "It's great that you've been so good about coming in every year to be checked. I wish all my diabetic patients were as careful about this as you are." A few simple comments make the patient aware that what he's doing is smart, safe and right to continue doing.

IT HAS TO BE FOR THEM

An annual exam may be the most common recommendation, but it isn't a "one-size-fits-all" option. We all have patients whose needs are adequately and safely met with re-examination on a bi-annual basis. If you want patients to believe you when recall on a 6-month basis is advisable, you have to be honest when recall every 2 years is a prudent schedule.

Remember this rule: Whatever is in the best interest of your patient, ultimately, is in the best interest of your practice. A doctor who genuinely puts the patient's best interests first in all decisions will readily be perceived that way by most patients. Advice that is perceived as being trustworthy and valid is much more likely to be heeded.

The general principle common to all of these techniques is providing patients with a viable and understandable motivation for routine examination that's in their own best interest. Presenting the rationale for routine examination in an effective way is, arguably, one of the most important clinical skills a doctor can have for providing the best possible care to a patient. 

Dr. Higgins is a 1980 graduate of Illinois College of Optometry. She has owned a private practice in Prairie du Chien, Wis., for 21 years.