Melissa Valdellon

Directing Your Patients

Your time is valuable. Your time with each patient is valuable. You need to be able to connect with your patients and guide them along the exam as efficiently as possible.

So for me, that means I generally ask more pointed questions rather than leaving things too open ended and broad. Even as I sit patients in their exam chair, one of my first questions is “how is your vision doing in the distance and up close?” If they start going into how their eyes are feeling or anything else, I acknowledge their points but redirect them, informing them that there are two parts to the exam, the vision part and the health part, and that I want to check the vision part first.

Most patients respond favorably to that and voila, you’re back in control of an exam that could have led you down a strange rabbit hole. At this point, I’ll ask my vision related questions and do my initial confrontation testing. Here, I have found that holding the cover paddle myself means I make sure the patient’s eye is appropriately occluded and they can’t push the paddle up against their own eye. It gives them less change to fumble too. Typically, I only let a patient handle equipment during pinhole testing.

Next, I repeat that the next part of the exam is where we’ll be evaluating the patients’ vision status and needs. During refraction, I really try to keep in mind that patients’ incoming visual acuity and anticipating how much change is required to get them to see their best – if any changes are needed at all. I also keep in mind that a patient can only tolerate maybe 0.75 to 1.00 diopters or 20 degrees of change in any direction at any time from their starting point for my final refraction. With that in mind, I don’t typically keep a patient ‘accepting’ a certain direction if they keep saying it’s better after 3 or 4 options, as I know that’s usually going beyond what I’d be changing the prescription by anyway (unless it makes sense with their incoming visual acuity!).

Once refraction is complete and I have demoed their new prescription, I tell the patient that we’re switching gears and going into the ocular health portion of the exam next. This is where I’ll usually ask about how their eyes feel in general as well as their systemic health, medications, and allergies. Then I tell them I’m going to use eyedrops to check their eye pressure. When I explain that the eyedrops are necessary to help with evaluating their eye health, most patients are willing to comply. I do the same when I later go to dilate their eyes, explaining that it’s the best way for me to make sure their eyes are healthy and free of diseases like diabetes and glaucoma. For me, I have found that by explaining what I’m doing rather than making the ask if I can use eyedrops first, I find that more patients are willing to be dilated for their ocular health check. Too often, I have heard my interns ask first and their patients declining more as a result even after explaining the reasons why dilation is important.

Remember, I’m trying to get the patient to work with me. Most of your patients will want to cooperate if it’s in their best interest. They just want to be informed.

Overall, directing how your patients answer your questions can help streamline your exam. For example, when asking about headaches, rather than asking them to describe their symptoms off the top of their head, I go into specifics using questions like – Is it sharp, stinging, boring? Show me on your head where the pain is. Does this happen every day or few days? Does this happen when you’re doing something like reading or watching TV or when you’re walking around?

Of course, you want your conversations to still be in the flow and natural, and I don’t suggest that every patient response should be some kind of forced response. Incorporating more directed questions and limited patient options during key parts of the exam though can help you keep your exam moving in the direction you need it to go and uncover information that is important to your management and treatment plan.

Happy testing!

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