Occasionally in clinic we will run into a difficult patient or a situation that will make us stressed and anxious. Sometimes patients may make us straight up angry. There are certain situations that can be extremely frustrating to students and OD’s alike that can make us want to scream and leave the room. No matter what happens, we need to be professional – we are the doctors, and your patient is coming to you because they see you as a valuable source of information and an authority figure.
Below are some patient care scenarios that you may encounter in clinic and some tips on how to diffuse a stressful situation to best serve the needs of your patient:
The language barrier
This can be extremely difficult to deal with for some students and a major source of exam anxiety. If your patient comes in for an exam and speaks little or no English, how are you as a practitioner supposed to help them? Even if you can stumble through your exam by pointing where you need them to look, using mostly objective testing, how can you explain your findings or get a history? These are usually the most vital points of an exam, and communication is essential to continuity of care. Rarely do patients come in and have no problems that need explaining. If possible, ask the front desk to have them bring a translator with them when the appointment is made. If someone in the office speaks their language, use that to your advantage. Keep in mind that some things may literally be lost in translation, especially medical nomenclature. Do the best you can. As a last resort, if the patient’s language is something abnormal or nobody is available to translate: download Google Translate onto your phone. If you speak slowly and clearly enough, it will give a rough translation on the screen and can be a lifesaver in a pinch.
Sometimes patients will come in and swear that they have gone blind. In all reality, they might have lost a contact lens, and they are a -2.00. The hypochondriac patient will overexaggerate every test, making all your results seem off. The VA will be CF at 2′ and the retinoscopy is -1.50 sph. Things just don’t seem to match. They tend to be dramatic personalities and sometimes can be spotted on their way into the clinic. These patients just need some reassurance that their eyes are FINE with correction. They need a little help from glasses, but they are by NO means blind. In these cases: rely on your objective testing as much as you can since they will likely be a poor responder. Other dramatic patients will come in for an “emergency” appointment. They may have a mild viral conjunctivitis and demand a prescription for antibiotics and painkillers: often they need palliative care and to ride the course. Others will be EXTREMELY photophobic and make your exam difficult. Be firm yet gentle in your delivery of the patient’s diagnosis and plan. Don’t get bullied into overprescribing when YOU know what’s necessary and best for the patient’s condition: whether that’s -0.50 more minus or Vigamox for a viral infection (which won’t do anything!).
The uncooperative teen
The teenagers that get dragged into the office by their mom for an exam can be some of the worst responders/patients out there. Teenager angst + the thought of needing glasses often does not make for a happy patient. Do as much objective testing as you can to avoid extreme responses, keeping in mind most of this age group will be emerging (or worsening) myopes. Some may have near BV issues depending on the amount of near work they do, and explaining bifocal options to a teen with image issues is an even more sore subject. Tread carefully. Many teens who have never worn glasses will immediately jump to the idea of contact lenses. Parents are often reluctant due to potential hygiene and responsibility issues. Giving a 3-6 month window in glasses before CL’s can be a good way to get the teen patient used to the Rx before jumping in with both feet. Explain to parents and teens that even if they choose contacts, backup glasses are ALWAYS needed due to potential infection/injury risk to the eyes.
The patient with special needs
Dealing with a patient with special needs can be a major challenge if you haven’t been exposed to such a patient base. In this situation, proceed with caution. Disabilities come in more than 31 flavors; every patient is different with a variable level of independence. Often the patient will have a caregiver or family member who can be of help when it comes to getting the information you need. That same person can also be helpful in letting you know if the patient may be very afraid or averse to certain procedures. I find that taking off my white coat and making the exam seem less clinical can help lessen some fears. Use as many objective tests as you can and assess the patient appropriately. Speak to them as much as you can instead of speaking to the caregiver. Depending on their level of handicap, they may be very self-sufficient and insist on doing many things themselves. Others may have too much of a handicap to even speak: get whatever test results you can. Be professional and very calm, even if the exam takes longer. Take breaks as you need to and come back another day if necessary.
Often we will have a patient with a clear cut diagnosis and will lay out a fabulous treatment plan for them. However, it requires them to use drops/patch their child’s eye/stay out of CLs, etc. All too often, patients are lost to followup or don’t comply. This can be infuriating to the student since we know what’s going to help the patient and yet they don’t seem to want to help themselves. Communication is the MOST important thing here: before the patient has the chance to be lost. The patient with an amblyopic child needs to be informed of the importance 0f compliance with patching therapy. If cosmetics or the child taking the patch off becomes a problem, atropine therapy may need to be discussed. For the patient with a bacterial corneal ulcer from CL abuse, it’s VITAL they stay out of lenses for the duration of therapy. They also need to know that the antibiotic therapy is essential to healing, and keeping with the regimen prescribed is necessary not only to healing, but to preventing permanent vision loss. In cases of glaucoma or more severe chronic diseases: these patients need one on one doctor counseling to know that they will need lifelong treatment to preserve what vision they do have.
In many cases, the reluctance may be financial in nature. When a drop is $100 and the patient doesn’t have insurance, they may be less likely to go to the pharmacy and use it, especially when the bottle is so tiny. They don’t see it as worth it, when what they’re really gambling with is their vision. When you tell a patient they need to stay out of contacts for a few weeks and they don’t have glasses: make sure they get a pair of backup glasses, even if it’s the $99 special for the time being. When patients come in to followup visits and it’s discovered that they haven’t been keeping course with your treatment plan, you need to be firm yet professional in your delivery of the news that them adhering to your plan is necessary. Using cause and effect and explaining consequences is very important.
The chatty patty
Older patients especially can tend to be rather talkative in their exam. This is often because they may not get as much interaction on a daily basis with people as they used to, especially if they no longer drive and are somewhat lonely in their homes. This can be problematic, especially during history taking when you need to get direct information, and quickly. What can be helpful if your patient starts rambling about their grandchildren and their trip to New York is if you politely say, “Mrs. Smith, I would love to talk with you later on in the exam: right now, let me get all the pertinent information I need to complete my exam.” Then use the times where it’s appropriate to let them chat (retinoscopy, pupils/EOMs, BIO – when you have some time and their head can move a little). This can serve double duty by keeping them awake and engaged during those portions of the exam when you need them focused.
In all cases of the less-than-flawless exam, make sure to COMMUNICATE with your patient. Oftentimes problems arise when patients don’t understand their treatment: patching, proper CL care, drop instillation, etc-often because these things were never properly explained. Many times, the patient just needs reassurance. In primary care, we will be exposed to patients from all walks of life. We need to make sure our heads are on straight to keep our patients on track.