WWJJD Part 1

As a young optometrist just starting out in your career, you may encounter some awkward situations during your working life that you may not know how to respond to. I ran a few scenarios by Dr Jenn of Eyedolatry and Dr Jackie of 20/20 Glance to get some pearls of wisdom.

A patient comes back to see you for the third time in four months “just for another eye test in case something has gone wrong”. They have no diagnosed ocular disease or vision disorders, nor do they have any significant risk factors. The only thing you can diagnose them with is hypochondria. They are taking up valuable chair time in your already busy practice.

JENN: If I have a patient that’s extremely nervous or apprehensive about the care I’m giving, I always encourage them to get a second opinion. I can recall at least two patients that presented to me with new onset floater complaints. We dilated, took retinal photos, did a thorough examination and all was healthy. Two or three days later they are back again, thinking the floaters are worse. We go through the whole process of dilation and full work up again, and yes, again nothing is going on in the retina– just floaters. At this second visit if the patient is still acting nervous or concerned, I propose to the patient getting a second opinion from a retinal specialist. I encourage you to find ophthalmologists in your area that are optometry friendly and will work with you on these high-anxiety patient referrals. I’ll send a little note explaining that I’ve done two dilated exams and seen nothing suspicious, but due to the patient’s high level of concern we are seeking their opinion as a specialist.  My thought is that the patient is going to likely seek another doctor’s opinion anyway.  If I support the feelings they are having, and offer them a qualified specialist that I know won’t bash my care at their visit, everyone wins.  Both of my high anxiety floater patients very happily came back to see me for their comprehensive exams year after year, and have sent me a ton of referrals!

JACKIE: Of all the scenarios, this is a pretty good one. You know this exam will be relatively quick since you just looked at this person 4 months ago and not much can really take a turn in 4 months. If it really bothers you to see this patient so often, you could spend some extra time to try and get at the heart of the worry. Did he/she have a family member or friend with a blinding condition and is that where the worry stems? If you can figure that out, you can probably use a little science to reassure them (i.e. choroidal melanomas happen in less than 5% of the population, you don’t have any risk factors for this etc.) On the other hand, if you think this patient is nice, you can always hint around about the fact that you like blueberry scones and maybe he/she will bring you one at each visit and then hey, free scone!

You have conducted an eye test for a male patient and are now discussing your recommendations for spectacles. He begins to get agitated and verbally aggressive, saying that you don’t know what you’re talking about and are just trying to make money out of him. Sexist and racist comments begin and at some point during the conversation he slams his fist on your desk.

JENN: Wow that escalated fast!  My first word of advice is that patients often don’t want to be told they need glasses.  I know this is crazy sounding; they scheduled the appointment because they had vision complaints, right? But time and again I’ve seen patients with vision complaints extremely frustrated or upset when I recommend glasses correction.  I try to start every never-worn-glasses patient the same way – I go into the exam room and start talking about positives first, then their complaints.  Look at the patient’s visual acuity; are they legal to drive without glasses? That’s a great place to start!

Hopefully with this patient-focused approach, we’ll avoid the uncomfortable combative front desk encounter, but I think we all know that can still happen. If a patient does escalate to threatening you or your staff, my best advice is to be swift and final.

“I’m sorry you weren’t happy with today’s examination.  What could we do to make this better?”

Ask them what they want.  A lot of times it throws the patient off and you find out they are just scared/confused/dealing with disappointment and feeling like what they want isn’t being heard by you.  Something they know you can’t fix.  I wouldn’t immediately offer them a refund, but if they say that’s what they want, just give it to them.  The headache of dealing with this customer is not worth the $25 their insurance is going to reimburse you for the exam.  The real key is not to argue back, just apologize and ask what they want you to do to make it right. This is a customer service industry after all, and patient de-escalation and accepting responsibility for the patient’s experience is just something we have to live with as part of our healthcare profession (unfortunately in some cases).  Most of the time, it’s not you or even your exam. The patient is just in a bad place personally, so we have to try to have some empathy. But don’t let staff take a berating and hope the patient will leave. Step in, stop it, give the patient a chance to tell you what they want and give it to them.

JACKIE: Goodbye. Nowhere in your job description does it say you have to put up with harassment. If you feel threatened, leave the room, get your office administrator or call the police if you are alone. And then fire him as a patient. Ain’t nobody got time for that.

Whilst conducting a routine eye test on a 10 year old patient, you pick up what appears to be a choroidal melanoma in the retina of one eye. The mother is sitting in the consult room with you.

JENN: My best advice here is don’t feel like you need to be the doctor to make this diagnosis.  You can express an appropriate level of concern (we don’t want mom to brush off the referral you need to make), but leave the actual diagnosis of melanoma or any serious sight or life threatening condition to the specialist.  I love practicing with retinal photography for this reason, so I can show the patient and parent exactly what I’m seeing and why I want it to be looked at by a specialist.

“Mrs. Smith, do you see that darker area in your son’s eye. This looks like a type of freckle, but just due to its’ size and location we should get a second opinion.  Dr. Jones specializes in freckles and growths in and around the eye, so I want to refer you over to his office since this is really his area of expertise.”

In my opinion, as long as the referral is made and you feel you’ve indicated an appropriate level of importance to this visit, you don’t have to stress the patient out unnecessarily.  If they ask what it could be, you can go into more details, but I would avoid saying “you have melanoma” and save that for the doctor who will make the definitive diagnosis. If you aren’t sure the gravity of the situation is sinking in, make sure you call mom and follow-up after their scheduled appointment time for the referral to see how things went.  If they skipped the appointment it’s time to ramp up your approach to make sure they get seen!

JACKIE: You have to walk very carefully when discussing a potentially blinding/life threatening problem you stumble upon.  I discuss what I see and if the patient/parent is nonchalant or I have any concern they may not follow up with the specialist, I throw around scarier words like blindness etc.   In this case, I would say that I see a freckle that looks a little bigger than normal and would like a retinal specialist to take a peek.  Then I leave the room, and speed dial said specialist to get them a same day appointment so I can sleep at night.

Thus ends the first instalment of WWJJD. Hopefully you have gained some wisdom-pearls, as well as the knowledge that Dr Jackie likes blueberry scones. Stay tuned for the second post coming soon!

A final pearl of wisdom before we part.

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