The Art of Compliance

Communicating with your patients can improve compliance when it comes to wearing contact lenses. In doing so, you’ll significantly reduce the risk of infections, save yourself time and increase your practice’s financial performance. 

In our December issue, in the article Science of Compliance, Professor Nathan Efron et al shared their research on how contact lens patients behave and the risks of various non-compliant behaviours. We learned non-compliance can be deliberate (rational or irrational) or unintentional (forgetfulness or misunderstanding) and that poor compliance reduces contact lens and lens care efficacy, increases adverse reactions – giant papillary conjunctivitis (GPC), keratitis – and wastes practitioner and patient time.¹ A list that says it’s worth spending more time upfront to help patients comply.

But patients are only human and encouraging good compliance is just as much art as science. Improving your ‘art’, essentially communication and service, also helps combat the ultimate non-compliance of patients taking their prescription elsewhere. This outcome is a win-win situation because the patient doesn’t lose touch with the professional, and it’s great for the practice financially. So how can we improve communication to improve compliance?

The Medical Interview

The Calgary-Cambridge Guide² is an evidence-based summary of the behaviours that improve doctor-patient communication. Revised over many years, it addresses patient needs and helps you find that something extra to elevate your service above the ordinary. The Guide’s main principle is to provide structure to help you think about where you are in the consultation process and what you want to achieve.  Structure in turn gives patients the confidence to make decisions.

The model also reflects that compliance is about people, not patients, and that for communication to be effective it must be from the patient’s perspective. We tend to think of signs, symptoms and treatments for the ‘disease’, whereas patients have concerns, beliefs and feelings about their ‘illness’.  Patients come to us for answers to life’s simple questions – what’s happened, why, why me, why now, what happens if I
do nothing, what’s the least I have to do? It’s much more personal than we think.

Consider the Evidence

Experience unfortunately is a poor teacher, so if you want to improve your communication skills, it is worth considering the available evidence. Split into six stages, the Calgary-Cambridge Guide overlays proven relationship-building techniques with efficient information gathering. If you can imagine communication as a spiral and with every reiteration and repetition you’re pushing the patient up or down the spiral. The aim of using a framework is to make sure you’re always pushing up.

Initiate the Session

Establish your role: If you want patients to follow your advice, be seen as an expert in contact lens technology. What does your practice say about contact lenses? What does the practice look like? How well trained are the staff? What is the priority given to contact lenses versus spectacles? How are appointments structured? What product is visible from the waiting area?

Listen: Once you have attended to the physical comfort of the patient, show interest by asking about their individual needs and listen to the answer without interrupting. Most of us practice diagnostic foreclosure where we make a clinical decision within about 18 seconds of the patient’s opening statement and then spend the rest of the consultation trying to prove we were right. Interrupting the patient like this can be interpreted by the patient as a lack of caring and may mean you fail to address their real concern.

Know who you’ve asked: Show you listen by keeping track of who you have talked to about contact lenses. Lisa Jansen optometrist, from Western Australia, uses a simple spreadsheet on her desktop to record which patients she’s asked, when and what their response was. It’s a simple tracking tool that gives you the confidence to raise the idea of contact lenses more often.

Think of contact lenses for life: Tell patients you expect them to be able to wear contact lenses for life and that at each subsequent appointment you will be able to show them what’s new. Be more confident about contact lenses generally.

Leading like this also makes it easier to charge professional fees. Patients paying fees are also less likely to discount your advice and if they do take the prescription elsewhere, you’ll feel like you’ve been compensated. Charging fees also makes it easier to spend more time on the contact lens fitting and education, which also promotes compliance.

Gather Information

Encourage the patient to tell their story: Investigate what ideas the patient has, their concerns and expectations. How do spectacles affect the patient’s life?  What did they like about the last pair? What could be better? What do they like about their current contact lenses?  Look at the evidence – their contact lenses, their cases, lens usage and ask them directly about what they are doing.

Get vision right: The NSIGHT study reminded us not to underestimate the importance of vision to patients.³ Always fit contact lenses from an up-to-date refraction, correct low cylinders and offer the option of multifocal contact lenses to emerging presbyopes. You’ll be repaid with loyalty.⁴

Talk hours of wear, not levels of comfort: Don’t talk too much about the feel of lenses, as most of the time lenses feel pretty good and the patient will use this as a rationale for overwear. Likewise patients can’t easily feel ‘efficacy’ so it’s helpful to ‘prescribe’ specific lenses and lens care on an individual basis and explain your choice to the patient.

Know the cost to try something new: Patients don’t think so much about price, but value. It will only cost you x to find out.  Often the incremental cost is much less than the gain. For example, as an add on to spectacles, if you start talking about the net cost of dailies, you will quickly make them a much larger part of your practice and also benefit from the improved compliance.

Provide Structure

Make organisation overt: Set an agenda with the patient upfront. Tell the patient what will happen at each step of the consultation process and ask permission before doing any tests. Setting an agenda from the beginning reduces uncertainty for the patient and gives more chance for the patient to raise the most important concern.

Summarise what the patient says: This shows you are listening, clarifies what the patient is saying and gives the patient time to think.

Use signposts: Signposts will help you keep the consultation on track, to show progression and remove uncertainty. For example, “Now we will move on to the contact lens fitting. There are two things we need to do. Firstly”

Relationship Building

Be confident: Be positive, but sensitive and show appropriate body language. Support new patients who will be apprehensive for the first application and the first removal of a contact lens. Tell them what went well – everyone wants a good report card.

Share your thinking along the way: “Right now, this is what I am thinking…”  Doing this involves the patient in the problem-solving process and helps you to reset expectations to realistic levels.

Involve the patient: Achieving compliance is about enrolling the patient and this is probably why the EASE approach (using contact lenses for frame selection) works. Patients get to try contact lenses in a low-key way, while doing a real task, and you get immediate feedback on lens performance.

Explain and Plan

Provide the right amount of information: Good communicators use explicit categorisation and limit the information; for example “soft contact lenses come in dailies or monthlies; there are three important things you need to do”. Use repetition and visual methods of conveying information (written, video, demonstration). Find the balance between explaining the sophistication of the technology and the ease of use.

Achieve a shared understanding: 
Ask patients to repeat your instructions or information in their own words. This encourages questions and helps you capture the patient’s perspective.

Share the decision-making: Provide your professional opinion but make sure you provide the rationale and seek the patient’s reaction. Relate your opinion back to the patient’s lifestyle and beliefs; for example “because you’re doing a lot of sport, I recommend…”. Encourage the patient to make decisions to the level they wish.

Negotiate a mutually acceptable plan: Explain contact lenses, how they work, the benefits and possible side effects. Obtain the patient’s perception of the benefits, plus any barriers to comply. The patient sees you as the professional and will respond if you encourage them to be self-reliant. “You can do it!”

Close the Session

Contract the next steps: Repeat the agreed plan. Offer a safety net for unexpected outcomes and explain when and how to seek help.

Provide follow up and support: If a patient does not return for aftercare, send a further invitation. If they do return, explore difficulties, including any change in attitude.

Combining Art and Science

Our fear with non-compliance is infection. Fortunately ocular infection is rare, but as professionals we still need to guard against it.⁵ Professor Efron’s article identified the common modifiable risk factors of infection, which are shown below. All, except for the use of tap water with lenses, increase the risk of infection by three to four times. Buying contact lenses online carries a similar risk (4.8 times),⁵ and is probably indicative of a less compliant patient generally.

If you outlaw the use of tap water, these similar risks make the overall message simpler (“doing xyz increases the risk of infection by four times). Knowing which patients are more at risk also helps you deliver a more personalised message. Many patients think they are compliant,⁶ so the aim is not to criticise the patient about what they did wrong, but to advise them how to get it right. Again, it’s about being positive.

Hand-washing: The Efron survey reported 26 per cent of patients don’t wash their hands before lens insertion and 47 per cent don’t wash for removal, especially young males. “A lot of people don’t wash their hands before touching their lenses, but if you want to minimise infection, always wash your hands with soap before putting you lenses in or out.”

Using solutions correctly: 42 per cent don’t rub the lenses, 27 per cent top off solutions, plus many are non-compliant with case hygiene. “It’s easy to not be bothered with rubbing the lenses (replacing the solution/case), but it makes a big difference to keeping your lenses clean for the whole month and reducing infection.”

Using solutions correctly: 42 per cent don’t rub the lenses, 27 per cent top off solutions, plus many are non-compliant with case hygiene. “It’s easy to not be bothered with rubbing the lenses (replacing the solution/case), but it makes a big difference to keeping your lenses clean for the whole month and reducing infection.”

 

Un-prescribed overnight wear: 40 per cent reported ‘accidentally’ sleeping in lenses.  “Everyone’s done it once or twice, but if it’s more than that, it might be safer to go to a daily lens that you can just throw out before bedtime.”

 On-time lens replacement: Similar to previous studies,^7,8,9 contact lens overwear was the worst with 2-weekly lenses (70 per cent), then monthlies (30 per cent) and dailies showed the best compliance (20 per cent). Non-compliant daily wearers are trying to save money. “A fresh lens will always feel better and replacing lenses daily is the lowest risk of complication.”  Others might just be forgetting. “I know it’s easy to forget, but the closer you are to the right date, the better it is for vision and the long-term ability to wear lenses.” Or it might be because they are asymptomatic. “Your lenses probably feel good, but the chance of a problem increases with each day you stretch, so if you want to stay symptom free, replace as close to the right date as you can.”

 Buying online: This not only increases the risk of infection, but USA data shows it reduces the number of patients returning for an annual consultation by 10 per cent and doubles the aftercares.¹⁰ Aim to tell patients what you can do: “we can organise your contact lenses and solutions today; we’ve got the stock here; we offer a discount for an annual supply; we can arrange delivery to your work”, and always keep the door open

Build in Compliance

Build in as much compliance as you can. Prescribe the best lenses and lens care for the individual patient and sufficient lenses to see them through to the next visit. This actually makes it easier for the patient. Ask patients to replace lenses on time and ask them to put a reminder in their phone while they are still in your room. Pre-book the next appointment, even if the patient has to change it. Make sure you’ve got a good recall method and have the systems in place so you can measure lens usage. Then if the patient is using fewer lenses than expected, you’ll feel more confident about having the compliance conversation. If you’re worried about a patient, reduce the aftercare period.

More About Online

If you ask a traditional optometry practice or any bricks and mortar retailer what makes them different, they will always say ‘service’.  But when you think about online shopping, you probably think more about price than service. But are online and offline that different?

Figure 1

Amazon has been celebrating its recent success with the Kindle Fire.¹¹ Looking like the first real threat to Apple, Christmas sales of the coloured version Kindle were over a million per week. Amazon reportedly sells the new Kindle at a loss, but expects to make money by giving customers easier access to buy Amazon digital books, music and movies. Go to the About Amazon page and you’ll find statements like “the earth’s most customer-centric company” and a strategy to “use technology to offer customers more types of products, more conveniently and at low prices.” It’s a simple business model to make shopping so easy that customers don’t even have to think. “Buy now with one click”… it’s all about service!

The transparency of the internet means that others can quickly follow suit. Online contact lens retailers are increasingly providing more service – a wide range of products and information, 24/7 ordering, worldwide delivery, 100 per cent satisfaction guarantee, even a version of one click ordering where the patient only has to enter their email address to reorder lenses.

Online retailers in general are looking for ways to improve conversion. They are improving website functionality to make it easier to find things, using third party endorsements to boost credibility and streamlining the shopping cart function to make it an even stronger call to action. “Check out now!”

Whether you are in a traditional practice or an online retailer, patients want service and good service promotes compliance. Telling someone what to do or just listening (especially when its only for the first 18 seconds) is not good enough. Instead it is about using your professional skills to help the individual and to anticipate the things they didn’t know they wanted.

Try a Little Harder

If you’re feeling under-whelmed by how you can get patients to follow your advice, or follow you at all, think about Avis. In 1962, Avis was just a little fish in the car rental industry and after thirteen years in the red, needed to do something dramatic. Avis took a long hard look at itself and decided to go boldly with “We’re No. 2, We Try Harder”. They were able to take a weakness and turn it into something that resonated with customers.

The rest of the Avis story is history and you can read about it in the original book on service differentiation, Eating the Big Fish.¹² Still relevant today, Eating the Big Fish is about how a challenger can thrive by thinking differently to the market leader. Instead of copying what the leader does, the challenger sets its own rules by turning the status quo on its head.

But you can’t just come up with a hollow claim. Bill Bernback, the brains behind the Avis advertising slogan said, “there’s no point making good ads for bad product” and encouraged Avis management to do a complete service overhaul before placing any advertising. Avis turned around within a year and their market share went from 11 to 35 per cent in four years.¹³

Improving your service

So if you are ready to ‘try a little harder’ with contact lenses you can start by thinking about the Calgary-Cambridge Guide and looking for opportunities to improve your communication and service. The contact lens cycle here gives an approach to examine your interactions with the customer including those that occur before the consultation and continue on after the patient has bought their first lenses. If your practice processes satisfy the patient, the cycle starts again, as you upgrade their contact lenses. From the contact lens cycle, choose which area you will focus on first and once you achieve the result you want, you are ready to look at a new area.  It’s a simple approach, but a good exercise to look at the steps incrementally, especially if you’re sick of being a little fish.

To earn your CPD points from this article, answer the assessment available at: www.mivision.com.au/the-art-of-compliance

Jenny Saunders MOptom MSc, is an optometrist and consultant to the ophthalmic industry. She coordinated the Air Optix Aqua Multifocal and Here & Now evaluations, and wrote this article on behalf of Alcon Ciba Vision.

References

1. Efron et al, The science of compliance, Mivision Dec 2011.
2. Kurtz SM. Doctor-Patient Communication: Principles and Practices, Can J Neurol Sci 2002;2 – S23-S29.
3. Saks A, Patients claim my vision comes first. Mivision, July 2011.
4. Ciba Vision Here&Now Evaluation, Mivision, January 2011.
5. Stapleton F et al, Ophthalmology. 2008 Oct;115(10):1655-62. 
6. Donshik P et al, Eye Contact Lens. 2007 Nov;33(6 Pt 2):430-3.
7. Tilia D. Lens replacement compliance: monthly disposable versus two weekly disposable. ARVO Abstract, May 2009.
8. Yeung et al, Optometry (2010) 81, 598-607.
9. Dumbleton et al, Cont Lens Anterior Eye. 2011 Oct;34(5):216-22.
10. Fogel J and Zidile C, Journal of the American Optometric Association. Jan 2008.
11. http://www.smh.com.au/digital-life/tablets/amazon-takes-bite-out-of-apples-market-share-for-tablets-20111204-1od6d.html#ixzz1ferDV7CF
12. A Morgan, Eating the Big Fish, John Wiley & Sons, 1999.
13. http://www.avis.com.cy/We_try_harder.html retrieved 19.12.2011.