It’s kind of like…
The art of patient communicationWritten by Peter E Wilcox, OD FAAO Friday, 01 February 2013
It is much easier to capture and retain a patients’ attention if they present with a corneal foreign body than it is to have the same patient listen to you explain the significance of their newly diagnosed – or ongoing – glaucoma. The range of significance of the various glaucoma conversations can be as seemingly benign as discussing the significance of a positive family history to as attention-grabbing as managing a case of painful, acute angle closure. Most of our glaucoma patients reside somewhere between these two extremes. The typically painless and frequently unremarkable presenting and ongoing symptoms associated with most glaucoma patients sometimes makes it difficult to convey the significance of this silent thief of sight. Poor patient comprehension partially linked to inefficient patient education contributes to the staggeringly poor compliance rates of glaucoma patients.
It is our responsibility to communicate with each patient in the ‘language’ that THEY understand. We both consciously and unconsciously speak differently to a child versus an adult and a less sophisticated patient versus a more learned one. This difference in communication styles is also influenced by the pace of the practice, the mood and personality of the individual doctor, and the level of interest and feedback queues from the patient.
It is our responsibility to seek the appropriate level and style of communication that is necessary to ‘reach’ the patient in the chair so they are more likely to become and remain compliant with their prescribed glaucoma treatment. Various analogies and metaphors may stray from their specific condition but these literary tools easily simplify a frequently complicated and lengthy discussion.
I pay a great deal of attention to the non-verbal clues the patient conveys. They guide me to my goal of: “Removing the question mark from the patient’s forehead”. Once I am assured that the patient shares my level of concern regarding their unique situation, I can then fulfill their other needs. The bottom line is that all the instruments, testing, thoughts, conclusions, diagnoses and treatment plans are worthless if you are not willing, or able, to make the patient ‘believe’.
I have all the standard and non-routine communication tools (posters, photos, brochures, OptoVue OCT results, visual field print outs, pachymetry data, EyeMaginations ™ educational vignettes and so on…). The motivation for sharing some of my non-routine communication techniques arises from a condensed series of similar responses from new patients who, over time, have transferred their care to my practice. The average response was: “I have learned more about my condition from you in one day than I have in all the years I have been treated’.
Analogies and Metaphors
What causes glaucoma?
An analogy: The eye is like a sink that has water entering from the spigot and exiting from the drain. The water can be coming in to fast or the drain can be clogged, or there can be a little of both occurring at the same time. The testing shows that we will use a medicine that will slow down the spigot… or we will use drops/laser to increase the flow of the fluid through the drain.
The still undetermined diagnosis:
Patients frequently want to know: “Do I have glaucoma?” and “How bad is it?”
An analogy: “Making a positive diagnosis for any medical condition has the same ranges of confidence. Any given patient may be 100% healthy or have 100% of the possible damage from a certain disease. I state that it is like having a football field which is 100 yards long, where everyone from the zero to the 50 yard line are “versions of normal” versus people from the 51 to the 100 yard line are “versions of abnormal”. The toughest people to diagnose are those between the 40 to the 60 yard lines.
I will state: “With all the test results we discussed, you are somewhere between the ‘Blank to Blank’ yard line. We will continue to follow you and see if any of the findings move you toward a greater or lesser yard line.”
It is my job to treat those who have glaucoma and not treat those who do not have glaucoma.
The significance of having a thick or thin cornea:
There are arguments among doctors regarding how the Central Corneal Thickness (CCT) influences the incidence or significance of glaucoma. A way to generalize and simplify this for patients is:
The Metaphor: The Three Little Pigs. The Big Bad Wolf blew on the straw house and the pressure from his breath easily knocked it down. It took him a few breaths to blow down the stick house and he could not blow down the brick house. Now, with glaucoma, the pressure comes from inside the eye. Our corneal thickness testing found that you have “eyes made of straw” (or thin corneas/eyes). They are more sensitive to lower pressures. We therefore need to be more cautious with your eyes and maintain lower pressures (or the opposite for “brick eyes”).
An analogy: If you had a house with walls made of 2 x2’s, or 2 x 4’s or 2 x 6’s, the thicker walled home could withstand stronger storm winds. The test results show that your eyes are made of 2x 6’s and I feel they can withstand a slightly higher pressure (IOP) with little or no added risk.
Another analogy: Corneas can be thin, average or thick. Imagine if the instrument we used to measure the pressure in your eyes (Goldmann tonometer) was called a “push-o-meter” or an “indent-o-meter”. It pushes on your eye until it starts to indent it. It is calibrated for an average thickness. So, if was calibrated to push in a party balloon, but you used a piece of plastic food wrap, it would indent the thinner membrane too soon and the reading would be artificially low. Conversely, if you used it to push in a hot water bottle, the reading would be artificially high. I see by our testing that you have corneas which are as “thin as food wrap”. That means the readings we obtain are artificially low. We need to take that into account when we make our decisions on what goal we want for your treated IOP’s. Also, don’t be tempted to compare the goals we set for you with the goals one of your friends with glaucoma may have.
Explaining a thinned Ganglion Cell Complex and nerve fiber layer:
An analogy: The part of the retina that this instrument measured was from some of the surface layers of the retina. When this Ganglion Cell Complex (GCC) of cells is healthy, they are fluffy like angel food cake. When they are unhealthy they become squashed down or thinned. The red and yellow areas seen on this map (OptoVue OCT GCC and corresponding RNFL maps) depict the thinned, or squashed down, areas of the GCC. You can see the areas where these surface layers of retinal cells have lost their fluffiness.
Another Visual Aid: I have an old cable with multi-colored strands/wires, which I believe my father used to test functional color vision. I use it to splay out the strands in a dual vertically arching pattern to show the patients how the nerve fiber layer tracks from the GCC to the optic nerve head (ONH). This allows them to see why GCC loss equates to a corresponding ONH defect. It also allows me to show the patient that more of the strands leave the eye at the “North and South Pole” (superior and inferior rim) of the optic nerve than those that leave at the “Equator” (nasal and temporal rim). This prop benefits the more inquisitive patients who are more likely than others to question “cause and effect”.
Explaining Optic Nerve Cupping:
We frequently try to discuss a 3-dimensional disease process with 2-dimensional images. This is hard for the patient to visualize.
The prop and the analogy: I call this my “Italian Glaucoma” prop. I have a partially filled glass canister of spaghetti noodles. I will hold the canister so the top is equal with the surface of my desk. I will point to the ceiling and state: “That is the cornea.” I will point to the desk surface and state: “That is the retina with a million light receptors all over the surface.” I will then point to the floor and state: “That is the brain.”
I will take a small handful of pasta noodles out of the canister and spread them out over the desk top with one end terminating at the same spot at the edge of the desk. I will state that the light stimulates the light receptors and then travels across the retina through lots of thin nerves (the spaghetti). Those nerves leave though a hole in the back of the eye (the canister) and travel to the vision centers of the brain.
I will then show a bird’s eye view of the pasta to the patient and show them the cavity/cup/central funnel. I state this is the cup in the optic nerve I was describing in the retinal photograph. I will then pull out a few of the noodles; since the noodles always fall to the sides of the cylinder, there is a ready-made cup. I then ask the patient: “If some light receptors on the desk die and the noodles associated with those light receptors die then the hole in the center of the optic nerve/canister gets bigger. I will let them see the cup and show them that the cup just got larger. With a pragmatic tone I ask: “HOW MANY NOODLES DO YOU WANT TO LOSE?” Their response is always: “NONE!” That allows me to follow with the simple explanation that it is OUR JOB (the Dr and the patient) to keep you from losing any noodles. Since there are a finite number of tangible noodles, I find that the patients frequently gasp, stare and flare their eyes in disbelief that this is happening to them. They follow the educational moment with some comment like: “Wow! That is a great way to describe what is going on…”
Explaining Visual Field Loss:
We know that visual field loss is a poor early indicator of glaucomatous damage. This fact can cause a patient with early disease (the 55 yard line) to doubt/question/be non-compliant with the prescribed treatment. When I sense this I will simplify the complexity of the redundancy of the visual system as follows. “Let’s say that the individual “light receptors” in your eye, which make up the fluffy “angel food cake”, are the same as the homes in the following example. Imagine if you live a neighborhood with a million closely packed homes, each with 5 neighbors. This neighborhood is also full of gossips who report anything that may happen in your yard. If one neighbor is not home (light receptor loss) and an event happens in your yard (your light receptor is still working) then the information will still get passed along (from the other neighbors). So, for something to happen at your home (light striking a photoreceptor) and for the information not to be passed along (to the brain) there has to be 5 empty homes (neighboring light receptors). So the death of some light receptors is not perceived. It takes a “street” or “neighborhood” of cell loss before a problem is perceived. You don’t want this to happen to your visual field. Despite the fact that your visual field seems fine (because of a built-in redundancy in the visual system) we have enough other information to treat you and avoid having to have you suffer from losses in your visual field.
So, why do I do this? Why do I communicate with my patient's this way? Why should you? I do it because it is part of my personality. I do it because of the positive feedback from patients who state they appreciate the fact that it is obvious that I find it important to clearly communicate with them in a time where that is less and less experienced in the Dr-Patient encounter. I do it because I know it is good business. It is a fact that many patients don't keep their follow-up appointments, especially for non-painful chronic diseases, especially when they may be self-pay, especially when rising co-pays are $50.00 or more, especially when an office may run behind and... The better educated a patient is regarding the significance of their condition, the more likely they will keep their follow-up appointments.
I am sure all of you use various other analogies and metaphors which seem appropriate for your personality. I hope my offering of some of these successful educational tools will be adopted as well as encouraging you to exercise your more creative side.