Article Date: 3/1/2007

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Skip the Treatment Plan until You Understand the Problem

KOETTING, ROBERT A. OD, FAAO

More than 30 years ago, L.L. Weed published his famous SOAP approach to problem solving: Subjective, Objective, Assessment and Plan. This old rule applies to more than contact lenses, and it certainly fits contact lens practice.

Subjective: What does the patient say?

Objective: What does your examination disclose?

Assessment: How do you assess the problem?

Plan: What are you going to do about it?

It all sounds pretty simple, but it requires some serious thought and the steps must follow in that order. The SOAP philosophy is designed to keep practitioners from jumping to conclusions.

A Learning Experience

My own experience with a sleep disorder certainly indicated that these fundamentals of problem solving still prove useful today and in another field.

In my subjective report to the sleep clinic, I reported being diabetic and suspected that my profuse sweating might result from some related disorder. The recent stock market situation hadn't helped my emotional balance, so that could likely have been keeping me awake.

I needed answers. Was my mattress too hard or was my bedroom too warm? Was I fatigued during the day because I wasn't getting enough sleep at night? Then, too, I had some upper respiratory congestion (later diagnosed as COPD), which prevented comfortable breathing at night. In addition, a slim possibility of a leaky heart valve existed. Perhaps I'd been drinking too much coffee. My subjective history contained at least a half dozen strong possibilities.

The clinic doctors then performed their objective exam. I spent two nights in the facility, where trained technicians observed me. They placed electrodes all over my body in a series of sophisticated tests. I was thoroughly impressed (especially by the cost). At this point it seemed that the SOAP formula should logically have called for an assessment of the problem.

You have sleep apnea, I was told. I was advised to start spending nights with a device called a CPAP (continuous positive airway pressure) so I could sleep comfortably. The plan of choice had obviously been selected.

I asked the doctor about the many subjective possibilities I had listed. His answer was reassurance that this expensive and cumbersome device would solve my problems - period. My insurance carrier must have agreed, so we moved swiftly from objective to plan, without so much as a backward glance at subjective or assessment.

You've probably guessed by now that my story didn't have a happy ending. In fact, after just a few weeks with the CPAP I found myself removing it in the middle of the night just so I could get some rest.

Don't Make the Same Mistake

The recognition of a problem, followed to its ultimate solution, was the standard of good patient care a generation ago in my contact lens practice.

Listen to and record your patients' subjective complaints. What are their subjective vision problems (as opposed to lowered acuity and matters you might observe but which don't annoy the patient)? What are their comfort problems? In short, what do they think is wrong? Regarding my sleep problems, I had provided plenty of clues that the doctor chose to ignore because they didn't fit in with his preconceived solution.

In-depth questioning of a contact lens wearer, for example, may reveal whether he experienced a drying sensation because the lenses were actually dry or because he simply perceived them as dry. Similarly, vision problems related to contact lenses are rarely confined to acuity. You need to consider night driving, glare, flare, lens movement, photophobia, haze and ghost images relative to other signs and symptoms.

Of course observations are important. That's what objective is all about. After that the time comes for assessment. What do you think is wrong? What may have caused this problem? How did it cause the problem? If your baseline information and collected data are adequate, the cause should be clear. If not, further testing is required.

Assessment means a great deal more than overview. It must indicate, in the fewest possible words, the problem's underlying cause without restating the signs and symptoms. Two or more problems may exist simultaneously, and you should note each.

Plan ahead. What do you think will correct the problem and how? Once you've properly assessed and described the matter, the plan should be obvious. Record detailed information for future reference, especially any alterations in lens specifications, medications or patient instructions. What will you do next if the plan doesn't work? A few seconds spent reviewing alternate solutions provides a perfect springboard into the next visit.

Record exactly what you told the patient. Far more than a face-saving device, a record of the exact parting words are precious to practitioner and patient alike. Thousands of arguments and lawsuits support the advantage of writing down advice and directions given to patients.

Solve Problems with Diligence

I'm not trying to imply that the SOAP method is, or ever was, foolproof. It's by no means a substitute for competence. But my personal experience with sleep problems seems to indicate that this historical approach still deserves a place in clinical practice. Or, to put it another way, please don't announce the solution until you understand the problem.

Dr. Koetting is a retired contact lens pioneer and author. He is currently a consulting editor for Contact Lens Spectrum.



Contact Lens Spectrum, Issue: March 2007