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
What does the patient say?
What does your examination disclose?
How do you assess the problem?
What are you going to do about it?
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
A Learning Experience
experience with a sleep disorder certainly indicated that these
fundamentals of problem solving still prove useful today and in
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.
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.
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.
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.
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.
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
recognition of a problem, followed to its ultimate solution, was the
standard of good patient care a generation ago in my contact lens
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
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
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.
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.
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
Solve Problems with Diligence
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.