Author: Melissa

I can laugh now, looking at the days when I would show up to early and pre-chart for every patient that was on my schedule for the day. Yes, it gave me an idea of what kind of day to expect, if there were any challenging patients to look forward to or if I was going to be able to catch up with some of my favorite patients. I inwardly chuckle now when I see my students doing the same thing.

When I was working on the Navajo reservation, however, I quickly came to realize that my schedule always changed. Forces outside my control would mean patients would miss their appointments and follow ups. Sometimes, that would be because of lack of transportation. Other times, there would be work they could not get time off for. It did not matter of the weather was rainy or snowy or sunny – the show rate varied all the time. And then we would get a lot of walk in patients who were okay waiting to be seen if no one showed up or urgent care patients needing a red eye treated.

Now that I am working in community clinics, it’s still the same. My patients still have to deal with transportation issues, time off from work, family obligations, and more. I’ve learned to not let that get to me. If I have a light day, great. If I have a busy day, great. The no show rate is highly variable. But what I do know is that when the patients do show up, they are serious about getting their eyes checked out and I am here to (hopefully) help them.

So what do I do when a patient actually shows up, especially if they are a return patient? I generally only look at 6 few things:

1. When was their last visit with us
2. What was their best corrected vision at the last visit (and put their last prescription in to the phoropter if applicable)
3. If their vision was not correctable to 20/20, why
4. Quick review of last chief complaint
5. Quick review of last plan
6. Quick review of any prescription eyedrops or medications

Any other details and specifics, I can look at again later when I’ve greeted the patient and after I have already started the testing.

This review should only take a minute or so, depending on the patient complexity. You don’t have to spend five or ten minutes going into all the details because things may have changed since the last visit and you need to prioritize the reason for today’s visit anyway, which may or may not match the last exam’s plan.

So in brief, I would suggest keeping the majority of your pre-charting to an efficient minimum so you can maximize your time with the patient in your chair.

What do you add or subtract from your pre-charting to help with your efficiency?

So I was speaking to my students recently about how a lot of the kids we see at this clinic are amblyopic and that they don’t see a lot of normal kids. I agreed, saying we are a referral center for the kids who have failed their vision screening either at school or with their pediatrician.

Somehow after that though, we got onto the topic of the malingering patient and how they had not come across one so far. I told them the stories of two of my patients who I remember to this day because of their stories..

My first patient was a 6 year old black male that I was seeing as a fourth year student at Bascom Palmer Eye Institute. The kid seemed like he was in good spirits and was enthusiastic to participate, but had come in because he had failed a vision screening. Throughout my testing, I had no idea what was going on for the first couple minutes because none of the letters he said for his vision check in the distance or near matched anything on the charts I had. When I did retinoscopy, I found a tiny amount of hyperopia, but nothing that matched his really reduced visual acuity. He did well on his color vision though, stereo was great, there was no strabismus on cover test, and his ocular health was completely normal.

I checked his VAs again after I dilated and confirmed that on a wet retinoscopy there was no sudden change in his prescription. I finally figured it out – every letter he saw on the chart, he added one more letter to it. For example, an A became a B. The O became a P.

It hit me that I had a brilliant kid in front of me who was so happy to have this attention on him – but I was the only one paying attention. His mom was in the room fussing with a newborn sibling and his father was in and out of the room on his phone the entire time.

I told the attending doctor that the child was fine but there was some social stuff going on that probably needed to be addressed. He comes in and tells the parents that the child is normal and doesn’t need glasses and sends them on their way.

My other story is about a girl, I think she was 8 or 9 years old, who came in and was literally bouncing off the walls the entire time she was here. She could barely stay focused to do VAs, asked about every little test, every little bit of equipment, wanted to touch everything – you know this patient, right?

She’s in the exam with her grandmother and from what testing I could do, this girl had maybe a +0.75 or +1.00 prescription. The grandmother had come in because she wanted to make sure the patient didn’t need a glasses prescription but that she had no other concerns.

After confirming that the prescription also did not change after dilation and her eyes were healthy, I spoke with the grandmother in the waiting room and let her know my findings. I also asked if the granddaughter had always been like this personality-wise, jut to see if they needed to be connected with other resources for behavioral issues.

The grandmother confided that the child’s mother had been murdered just a month or two prior and everything had been stressful what with court stuff and all. She was grateful I could confirm that nothing was wrong with the child and we agreed that it wouldn’t hurt to give her a mild prescription to see if it would help her focus with her homework at least and just see how things go.

My heart broke with each of these patients who were obviously going through huge family changes and were reacting the only way they knew how. That being said, I knew I had a job to do, to make sure these kids’ eyes were healthy and to make sure they had the right prescription if needed. Outside of that, it was my place to be a listening and open ear to a grandmother worried about her granddaughter and a nice doctor who could spend some quality time with a child and pay attention to them when no one else could.

Be patient with these individuals. They may be some of the most frustrating exams ever, but there is a reason for their ‘acting up’. It’s our job to find out why and see how we can support them.

What’s your story with malingering patients? Care to share here?

One of my students recently brought up a good case of discussion. She was working with a 65 year old Asian female who came in for her annual exam reporting that her vision was not as clear anymore.

She had last come into our clinic in 2021 and due to cataracts, was best correctable with the following:

OD -3.00 -0.50 x 060  20/40
OS -1.25 -0.75 x 120  20/50

This is in comparison to refraction results from 2019:

OD -4.00 DS               20/40
OS -0.75 -1.75 x 120  20/40-2

Both times, she’s been noted to have moderate mixed cataracts in both eyes but she wasn’t ready to pursue cataract surgery.

When she came in for this year’s exam, however, she was wearing something completely different:

OD plano -2.00 x 090  20/200
OS plano -2.00 x 093  20/50

The student also did auto-refraction before bringing starting her refraction and got this:

OD -5.00 DS
OS -3.00 DS

Afterwards, the student let me know that with all the different data, she didn’t know where to start her refraction so she had started with a random one and tried to work with them all to see if she could get anything better.

Her final refraction ended up being:

OD -5.00 -1.00 x 120  20/40–
OS -3.50 -2.50 x 156  20/40–

The patient was told about her cataracts again and she was now ready to pursue surgery since we mentioned that we’d have to change her prescription a lot for minimal gain in clarity.

After the patient left, the student and I discussed how she could have had a smoother refraction, and it relates to simply asking a couple extra questions:

The patient had mentioned her vision was more blurry. Where were things clearest? With the pair of glasses she brought in today, with an older pair she got from us previously, or without glasses at all?

The student recognized how getting this extra info could have directed her to a better starting point for refraction. She already knew that the patient’s cataracts were affecting the best visual acuity for a number of years now and that refraction was unlikely to yield anything better, but it would have saved her time knowing which direction to start from.

I hope this helps drive the point of asking more detailed questions when the data doesn’t make sense. It doesn’t hurt to clarify things in a way to help you understand the patient’s point of view or expectations, and it makes them feel like you’re invested in working with them to find the best solution for their needs. Win-win for all.