Taking a Thorough, Meaningful Patient History
Answers to certain questions determine which patients are good candidates for contact lenses.
You know that taking a patient's medical and ophthalmic history influences a doctor's diagnosis and treatment decisions. The information you receive also helps determine if the patient is a candidate for contact lenses.
The key to knowing who the best candidates are lies in the answers to certain questions. "A patient's history is one of the most powerful tools an optometrist has," explains Donald J. Siegel, O.D., of Sun City West Eye Care, in Sun City West, Ariz. "Before we correct vision with contact lenses, we need to take a thorough history to determine what else may be contributing to a patient's vision loss."
"The patient history is the number one most important aspect of our jobs," says Don R. Smith, N.C.L.E. certified, team lead supervisor of the contact lens department at Park Nicollet Health Systems in St. Louis Park, Minn., one of the largest clinics in the Midwest. "It not only influences decisions regarding contact lenses, it's also essential for good health outcomes."
Ask the right questions
Answers to questions that focus on the patient's general health, eye health and medication use are the most telling.
General health: Most practices provide a standard form in the reception area. Patients list known medical problems, family medical history, symptoms and complaints.
Dr. Siegel advises his staff to not rely on the information on the forms because they're only a starting point. However, a good history can be obtained only when sitting face to face with the patient. You can ask questions that expand on the answers given on the form. "It's natural for staff to look at patients and think, 'This young patient is healthy, or this older patient must have health problems,' but we can't judge people that way. We must ignore appearances and learn to ask targeted questions to achieve a thorough history," he explains.
|In this issue:|
Taking a Thorough, Meaningful Patient History
Fitting Children for Contact Lenses
General health problems, such as significant ocular allergies, dry eye, or systemic diseases like Rosacea or Sjögren's syndrome that are associated with dry eye, all influence Dr. Siegel's decisions to prescribe contact lenses.
|A patient's history is one of the most powerful tools an optometrist has. Before we correct vision…, we need to take a thorough history to determine what else may be contributing to a patient's vision loss.|
— Donald J. Siegel, O.D.
Medication list: An accurate medication list is more informative than the patient's answers to questions about general health, Dr. Siegel says. "Many of my patients tell me that they don't have high blood pressure or diabetes, but they list drugs for these diseases," he explains. "When the staff call patients in advance and ask them to bring in a list of their medications, we are more likely to get an accurate list." The list should include all prescription and over-the-counter medications. Two types of drugs that will influence decisions to prescribe contact lenses include:
■ Medications known to cause vision loss. Drugs like amiodarone HCl for arrythmia or tamoxifen for breast cancer can cause vision loss unrelated to refraction, Dr. Siegel says.
■ Drying medications: "Certain drugs prescribed for acne and asthma can make the eyes especially dry, and this influences the choices of lenses, solutions, wearing schedule and duration," Mr. Smith says.
■ Contact lens background: It's important to ask patients what they want, need and expect from contact lenses, Mr. Smith says. "If the patient failed with contact lenses in the past, why did that happen? And why does she want to try again? These answers help evaluate the patient as a candidate, and they help the doctor choose lenses and solutions."
|It's important to ask patients what they want, need and expect from contact lenses. … If the patient failed with contact lenses in the past, why did that happen? And why does she want to try again? These answers help evaluate the patient as a candidate, and they help the doctor choose lenses and solutions.|
– Don R. Smith, N.C.L.E. certified
Continue the contact lens discussion
The contact lens background can lead to a discussion about the patient's lifestyle. "I want to obtain facts about the patient's environment and how he uses his eyes," says Ledonna Buckner, F.C.L.S.A., manager of contact lens services at Virginia Eye Institute in Richmond. She asks about sports, hobbies, computer use and other activities, as well as whether the patient plans to wear contact lenses daily or intermittently. According to Ms. Buckner, "Answers to all of these questions will help eyecare practitioners make the appropriate decisions on material, wearing schedule and lens care products." ■
Are Children Too Young for Contact Lenses?
Learn how to determine if a child is too young to be fitted and how to answer those FAQs.
At what age can a child begin wearing contact lenses? The answer varies depending on whom you ask. Some optometrists will fit children as young as 8 years old to take advantage of the ample opportunities to offer a variety of lenses to improve their vision and fit their active lifestyles. Others are more conservative and will wait until children turn at least 12 or 13 years old.
Doctors weigh many factors before prescribing contact lenses to children. It's important to know what those factors are and how to answer questions from parents and children who are considering contact lenses. "There's no magic age for contact lenses," says James E. Winnick, O.D., F.A.A.O., of Livermore Optometry Group in Livermore, Calif. "Anatomically, there's no reason why children can't wear contact lenses. It mostly comes down to maturity. Some 6-year-olds are more mature than some 26-year-olds. However, most kids first ask about contact lenses in their early teens for sports or appearance."
However if it's the child's first time for vision correction, Dr. Winnick will prescribe eyeglasses. "We can talk about contact lenses next time. First, they need to experience the benefit of their refractive correction. They should have a backup pair of eyeglasses anyway if they choose contact lenses later."
Steve Cogger, F.C.L.S.A., a contact lens specialist at Theo E. Obrig Inc., New York, N.Y., says he decides which children are the best candidates for contact lenses on a case-by-case basis. "We observe the child's maturity and the relationship with the parent," Mr. Cogger says. "We talk to children about the responsibility of caring for contact lenses and observe how they react."
Dr. Winnick says he discusses responsibility and costs with children and parents. He makes sure the child isn't squeamish about touching his eyes and observes the condition of the child's hands and nails. "Kids need to practice good hygiene because they have to do all the insertion, removal and cleaning," he explains. "If parents plan to do it, the answer is absolutely 'no.' If the child can't do everything himself, he's not ready for contact lenses."
Daily disposable contact lenses, such as Proclear® 1 Day (shown here), are a great option for children with active lifestyles. The lenses are convenient and easier to care for than traditional lenses because children can dispose of them at night and replace them in the morning with a fresh pair.
|"Daily disposables are my first choice if the child is eligible. … If the child's fitting requirements don't allow for the use of daily disposables, I will recommend a gas-permeable or silicone hydrogel lens."|
– Jim Winnick, O.D., F.A.A.O.
And in every case, contact lenses have to be what the child wants. "We only fit young children if they request contact lenses themselves – not if their parents prefer they wear them," Mr. Cogger says. "We discreetly ask the parents who actually wants the contact lenses."
Lenses and training
Once he's ready to prescribe contact lenses, Dr. Winnick offers several options. "Kids have the same problems as adults – cleaning, care and replacement. Daily disposables are my first choice if the child is eligible. Rebates often make the cost of these contact lenses competitive. If the child's fitting requirements don't allow for the use of daily disposables, I will recommend a gas-permeable or silicone hydrogel lens."
Training for insertion and removal is the same for children and adults, "although most children are more attentive than adults when they're learning about their contact lenses," Mr. Cogger says. "For younger kids, we want the parents to understand the process of lens care and handling as well."
These answers to the most frequently asked questions about contact lenses from parents – and children – will give them some good background information before they see the doctor.
Q. How old do children need to be to wear contact lenses?
A. There's no set age. The doctor's decision is based on several factors, including the child's maturity.
Q. Will wearing contact lenses make my child's vision worse?
A. No, the lenses won't have a negative impact on vision.
Q. Are contact lenses healthy for long-term use?
A. As long as the child uses the lenses as prescribed, they are safe for long-term use.
Q. Are contact lenses safe for sports?
A. Contact lenses are safe to wear and often more convenient for sports.
Q. What about swimming?
A. Wearing contact lenses while swimming isn't recommended. Lenses absorb the substances in the water, which can lead to infection. However, if there's no alternative, daily disposables provide the safest option, although you must dispose of them after swimming in a pool or spa water.
Dr. Winnick warns, "Parents are there to listen, but if they're contact lens wearers, too, they tend to want to take over the conversation. I want the child to learn our recommendations for insertion and removal, not necessarily adopt the habits of their parents." ■
Learn how to handle, schedule ocular emergencies while keeping the office running smoothly.
When patients call the office asking to see the doctor immediately or to schedule future appointments for potentially serious problems they don't believe are urgent, you need to decide quickly whether or not it's a true emergency.
How you handle urgent requests and make these important decisions often will determine the long-term visual health of patients. A poor judgment call can lead to unnecessary patient discomfort, visual impairment or even vision loss. Read on to find out what steps you can take to triage ocular emergencies effectively.
Front-desk staff who answer the phones play an important role in handling emergencies. "They're the gateway to the doctors," says Beth Kinoshita, O.D., F.A.A.O., assistant professor and chief of contact lens services at Pacific University College of Optometry in Forest Grove, Ore. "It's an extremely important role, deciding when we'll see patients while keeping the schedule running smoothly."
Linda Conlin, field support manager for a multidisciplinary practice, in Fairfield, Conn., and owner of F.E. Enterprises, which provides continuing education for opticians and ophthalmic technicians, agrees. "When someone calls for help, the staff member becomes part of the treatment process for that person. The employee's ability to gather information, assign a priority and make a decision about how to direct the caller not only affects the treatment the caller receives from beginning to end but also patient flow."
Source of stress
As you already may know, managing emergencies can be stressful because patients who call in generally are very concerned. "Several factors, such as other health issues and a person's state of mind, can make an otherwise minor medical problem seem like an emergency," says Terri Klein C.O.M.T., F.C.L.S.A., of North Suburban Eye Specialists, Coon Rapids, Minn. "We need to stay focused, look past the panic and not allow stress to dictate the conversation."
The call may be from a patient who has a serious eye or vision problem or from a patient who's calling for a family member. "The person may be in a highly emotional state, and that stress transfers to the staff," says Ms. Conlin. "Good training and a written set of guidelines, however, can reduce that stress and help staff handle emergencies more effectively," she adds.
According to Ms. Conlin, most doctors set guidelines for telephone triage and train their technicians. They might deal directly with all emergencies, assign a 'go-to' person, such as an office manager or technician, or give the staff specific instructions for handling different types of emergencies. "Written guidelines are an important reminder to staff, and they boost the staff's confidence," she adds.
Dr. Kinoshita says that good telephone triage starts with the right mind set. "Our staff who handle telephone triage think in terms of patient health, as well as scheduling," she explains. "They have written guidelines that say who we need to see immediately – basically, anyone with a painful red eye, sudden vision changes or loss, or other acute symptoms or acute onset of symptoms. Patients with a foreign body in the eye, burns or trauma also need to see the doctor or visit the emergency room right away.
|"When someone calls for help, the staff member becomes part of the treatment process for that person."|
– Linda Conlin
"Our staff listens for key words like 'progressively worse,' or 'fading in and out," ' Dr. Kinoshita adds. "And they know why they're looking for these symptoms. We explain that patients may have issues with the retina or the optic nerve head or eye infections – life-altering, sight-threatening health complications that need immediate attention. So we need to see them right away."
|Is it Really an Emergency?|
Beth Kinoshita, O.D., assistant professor and chief of the contact lens service at Pacific University College of Optometry in Forest Grove, Ore., says the following symptoms and ocular injuries should be considered acute emergencies:
■ A painful red eye
■ Sudden vision changes
■ Sudden vision loss
■ Other acute symptoms or acute onset of symptoms
■ Foreign body complaints
Handling the crisis
Sometimes a patient's urgent phone call is really an emergency, and sometimes it's not. But knowing what to say can move the situation forward. "When it's an emergency, our discussion with the patient often is short because we want him to come to the office quickly. We might say, 'I think it would be a good idea for you to see one of our doctors today. How soon can you get to our office? The doctor will see you as soon as you arrive and help you feel more comfortable,' " Ms. Klein says.
Ms. Conlin believes this approach is effective. "In an actual emergency, the staff member must remain calm," she says. "The caller may be panicking and unable to communicate the problem clearly. You must guide the patient through a series of simple, direct questions and be alert to keywords that indicate pain, sudden loss of vision, bleeding, trauma and so on. And make the instructions very plain."
When the call isn't an emergency, Ms. Conlin cautions staff about sounding dismissive to the caller. "Keep in mind that the patient was concerned enough to call. Explain why this isn't an emergency and avoid phrases like 'calm down' or 'it's nothing,' " she says. Instead, Ms. Conlin encourages staff to show concern for the patient. "Gather more information, tell the patient to call right away if the problem gets worse, and make sure the patient has the practice's on-call emergency phone number so he can call anytime. And most importantly, call the patient the next day to find out if the condition is improving or has worsened."
At the practice in which Ms. Klein works, the technical staff or even the physicians may contact nonemergency patients. "We also let patients know, depending on the problem, that if it will make them more comfortable, we can add them to the schedule within 48 hours."
With respect and a cool head, you too can help make sure emergency callers stay calm and get the care they need. For more tips on patient management, CooperVision offers the Online Learning Center, an invaluable education resource that provides training, support and continuing education on a wide range of topics. ■
Contact Lens Spectrum, Issue: December 2007