help me with this patient please

[optical24/7]

Refer to post #2.

[D.J. Roff, ABOM]

Wouldn't it be nice to have a data base of names of these patients.:shiner::idea:

Nah, I look at them as a challenge. And if you can make one of them happy, you have a friend for life... along with all his/her other anal-retentive friends, of course.

The worst one I had like this was a civil engineer... who also had a heavy stutter. Each time I saw him walk in, I knew I could kiss the next 90 minutes goodbye. :(

[OHPNTZ]

The fact that she refused to have her exam completed makes her a liability waiting to happen. Obviously she doesn't care about her eyes or vision.

On top of that she jumps around from office to office...also a huge red flag...

Save your time, save the doctor's time, and tell her to seek a second opinion...

[Happylady]

Magic shelf?

:)

[Robert Martellaro]

To answer a few questions:

-Pt is in her mid 40's

A +2.25 Add is unusual for this age with healthy eyes. This needs clarification.

[drk]

Hmmmm....good pick up, Robert....

[RKJ]

I’m thinking like DJ Roff. What if we gave this patient the benefit of the doubt? I'm thinking like Robert Martellaro, the symptoms sound computer related. I am new to a bulletin board format and realize some patient profile information should remain confidential, so let’s think of a hypothetical – a tough case we would be motivated to win:

What if this is a busy woman with family and work responsibilities; she really does have sensitive eyes and the belief that, regardless of what she actually tells the doctor, if doctor measured her prescription correctly, then she should have comfortable clear vision. We still don’t know her occupation and visual demands. Let’s say she just changed jobs and now spends 60% of her workday at the computer. Add something attractive to the business like 3 family members due for exam and a volunteer position like PTA president of the elementary school across the street. Plus finances are not a problem. She wants to look great. KElenor won over this patient through frame adjustments; the optical is close to patient’s work and home, so the patient is willing to make a purchase. We want to win this patient.

Given the hypothetical case, we can guess or infer from what we know:

· Her chief complaint of “I want new glasses” is probably an understatement. If she just wanted her same prescription in a new frame, we’ve pretty much done that, so she should be happy. She is not happy, so most likely she was expecting something else. Maybe she has a real problem and needs a better solution.

· Usually, patients have reasons for their behavior. Also, KElenor recognized this woman’s frustration and has a sincere desire to help. We consult colleagues when we believe there might be a reasonable solution. Though it seems the office did not have the woman’s confidence, this patient paid the money, shows up; she is not asking for a refund. She is trying to communicate. She trusts the frame adjustments. The patient may have legitimate reason for frustration. And we all know the remakes were pretty much the same. It’s not surprising we don’t have an “oh wow” – and she still experiences discomfort at the computer and distance blur after near work.

· Guessing 44 yrs, she is measuring a relatively high add for her age.

· She has moderately high cylinder; the measured amount of cylinder fluctuates; the axis seems stable.

· When she wakes up in the morning and turns to see the clock, probably she can squint and see. When she walks out to make coffee and check her computer email, probably she can squint and see without glasses. She has a natural mono-vision status when squinting without glasses. I'm still wondering how she wears her glasses, why the glasses need continued repair, and her natural binocularity.

· She is at the age where she will become dependent upon the add to see clearly and is finding her window of reading clarity is shrinking, to what the glasses provide, as her ability to accommodate decreases. She probably thinks ‘new glasses’ will solve the problem. It is frustrating that doctor says the prescription didn’t change much. She expects to pay money and see better.

· She has the kind of prescription that measures differently depending upon lid posture behind the phoropter and the status of accommodative spasm due to tired eyes. She can strain a little and see 20/20 even if the spectacles do not have her full cylinder. She can easily measure a deceptive 20/20 so her acuity alone does not prove the prescription measures are accurate. It is an advantage to witness the refraction because we learn from observation during testing.

· Moderately presbyopic, visually fatigued, individuals with uncorrected astigmatism and accommodative spasm – generally – will complain of “sensitive eyes”.

· This is the kind of prescription that has to be made accurately for her to see her best. It would not be surprising to learn she has had some bad experiences with remakes in the past.

· Finally, she may have recent experience with multiple providers; she might be tired and frustrated with probing and bright lights. She believes she has no eye disease at this point and is only willing to continue paying for the refraction. She’ll say what she needs to say to get the refraction and try the glasses. She might appear harried and unreasonable.

To Do:

1. Identify the chief complaint. What does she see great with her old glasses? What does she not see great with her old glasses? What are her symptoms?

2. Identify visual demands. occupation, hobbies…

3. Get previous records. If she has experience with other providers – do her a big favor – don’t re-invent the wheel. Figure out what testing she has experienced, what glasses did not work in the past,…

4. Get some objective data to corroberate best prescription. Has anyone done topography? How much cylinder does she really have? Has anyone measured her cycloplegic refraction? We would like to know about cylinder and accommodative spasm? Has anyone tested her binocular status? When you have previous records and some history, explain which tests results are missing and why you need the data.

5. Re-think the best lens solutions. Explain the options, the benefits and reasonable expectations. Sometimes we own more than one pair of glasses and select the best compromise because one pair can’t meet all the needs. You can gain trust, and establish your expertise, while respecting her time, and without probing her to death. In the long run you will save her heaps of time going through this again with someone else.

I agree with Idispense. Once you know what you want to prescribe, get a rep involved. A good rep will be pleased to invest in providing a good solution because this patient can be trained to be brand loyal. This becomes a win-win for the rep. He supports you, supports the patient, and will increase purchases over the lifetime of this patient – good for his employer.

This is the kind of patient who might become your patient for life. Solve her problem, coach her through adaptation to best choices; you might meet everyone she knows.

It might be really easy. Go through the motions to confirm her accurate prescription; explain assessment and recommendations; and order the most appropriate lens system for computer use in her work environment.

Do Great!
RKJ