dry eye

Establish the Dry Eye Disease Visit

When you discover this, among other ocular conditions, during the comprehensive vision exam, it requires an exclusive visit.

MELANIE J. DENTON, O.D., F.A.A.O., ASHEVILLE, N.C.

Until just a few months ago, I was guilty of a practice I like to call the “all-inconclusive exam:” I would listen to my patient’s initial concerns, perform my annual comprehensive exam and then attempt to address each and every medical eye finding right there and then. This process was extremely time-consuming and yielded far too much information for the patient to wrap his/her head around. The latter, I found, resulted in poor understanding of his/her condition(s) and non-compliance to treatment. To change this, I embraced the “medical exam,” or follow-up visit, at which I address the medical eye finding from the comprehensive eye exam exclusively.

A separate medical visit sends the message to the patient that the discovered condition is important, and it provides me with ample time for patient education, management and to address their concerns, all of which engages the patient in their care. The end result: Patient satisfaction, which creates patient loyalty and referrals and a growth in practice revenue.

Here, I discuss “how” to provide the separate dry eye disease (DED) exam.

1 Provide a DED questionnaire.

To distinguish the DED exam from the annual comprehensive exam for the DED patient, train your staff to provide these returning patients with an ocular surface disease questionnaire upon signing in for their appointment. These questionnaires: the McCarty symptoms questionnaire, Ocular Surface Disease Index, Schein questionnaire, McMonnies questionnaire and the Impact of Dry Eye on Everyday Life (IDEEL) questionnaire. (You can download these questionnaires via the Internet, or use a personal questionnaire.)

These questionnaires qualify and quantify the severity of signs and symptoms, facilitating our ability to determine the possible cause(s) (e.g. autoimmune disease, environment, medications, etc.). This enables us to then tailor an individual treatment plan that will positively affect the patient’s outcome. Also, these questionnaires confirm to these patients that DED is a serious condition, and thus, justifiably warrants an exclusive appointment.

2 Educate to influence.

As optometrists, we are faced with the task of not only recalling what we know and applying it to the patient, but more importantly, we are each tasked with the often difficult job of creating partnerships with our patients that foster the active engagement necessary for care that provides value and an improved outcome. To successfully create this partnership:

► Provide easy-to-understand education on the condition and the reasoning behind the treatment plan. In the case of DED, tell the patient:

“Dry eye disease is a chronic and progressive condition that has no cure, though several ways exist to manage it. To manage your dry eye disease, we’re going to _______, which has been shown effective because it __________.”

Explaining the nature of the disease enables the patient to understand exactly what is necessary to keep it under control.

Then, allow ample time for the patient to present his/her own perceptions, personal practices, life events or other matters that may affect the treatment outcome or your management.

► Be candid regarding treatment limits and constraints to care, and inform the patient that he/she, in turn, must be open to sharing all relevant health, economic and social circumstances, as decisions are best made with a complete understanding of the situation at hand. Say:

“Symptom relief is relative to each patient, so we’re going to have to work as a team to find the proper combination of treatments that will work best for you. To arrive at the best management plan, I’m going to need you to come in for regular follow-up appointments at which we can assess the various treatments. I’m also going to need you to inform me of any changes in your health or in other areas that you think may influence treatment choice. What do you say? Can I count on you?”

Setting expectations upfront results in better care, as the patient is more inclined to see the value in follow-up visits and continued treatment.

In the book The Art of Influence: Persuading Others Begins With You (Crown Business, 2008) author Chris Widener writes,

“True influencers put other people at ease and let them feel that they are the ones in control, and they are the ones in control… don’t ever forget that.”

This statement is resoundingly true for our patients. We only have 15 to 20 minutes to achieve a level of influence that will change their behaviors for the next 129,600 minutes (if we schedule a follow-up visit in three months, for example). Our patients are ultimately in control of their own care. We exist to guide and positively influence them.

3 Supply a personalized treatment summary.

After you’ve educated to influence, give the patient his/her own personalized treatment summary to take home and follow, and say,

“Think of this sheet as your homework. It contains all the treatments we’ve discussed, their dosage, frequency of use and when you should come back to see me.”

The treatment summary sheet should include all DED treatment options with corresponding lines for check marks so the patient knows what he/she should use. (See “Treatment Guide,” below.) Such a sheet is easy to follow and prevents prescription pad use — something that takes up time, becomes redundant for you and is often difficult for patients to read.

The Treatment Guide is a checklist provided to the patient that reinforces the points discussed during the exam. Practices, such as Envision Eyecare, print specific brand names of treatments on their guides (e.g. “ABC Artificial Tears”) based on the doctor�s recommendation.

A personalized treatment summary helps reinforce the points you discussed during the exam, while aiding in instilling the importance of patient compliance and his/her role in the aforementioned partnership.

4 Provide treatment strategy sheets.

Create forms that carefully explain “how” to use the treatment(s), as doing so aids in patient understanding and, thus, compliance and safety.

For example, a form that explains the purpose of warm compresses and outlines the procedure for a proper lid scrub using illustrations is very helpful.

5 Reinforce follow-up.

The final step in providing the separate DED exam is to reinforce the importance of the patient adhering to their followup appointments. Say,

“Following-up with you is the only way to ensure my treatment interventions are providing you with the greatest relief. So, it’s imperative you come for each and every appointment.”

Russian wisdom

Leo Tolstoy once said, “Everyone thinks of changing the world, but no one thinks of changing himself.” As guardians of sight, if we hope to change the behavior of our patients such that it improves their conditions, we must first look inward, and change our own. In this case, it’s time that we, as primary eyecare providers, establish the DED visit, among other exclusive medical visits. OM

Dr. Denton graduated from the Michigan College of Optometry in 2009 and completed a one-year residency in ocular disease at the Bascom Palmer Eye Institute at the University of Miami. In addition, she serves on the Ocular Surface Society of Optometry executive board. She is currently in private practice in Asheville, N.C. E-mail her at melaniedenton@gmail.com, or send comments to optometricmanagement@gmail.com.