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The Reluctant Patient
2 CPD in Australia | TBA in New Zealand | 30 January 2017
By Esther EuripidouApprehension or even anxiety relating to presentation for a vision or eye health examination can prevent a conclusive and comprehensive result. Strategies for approach need to be tailored for sensitive patients.
One of the joys of optometry is that we never know what experience will transpire from each day. Connecting with our patients so that loyalty and trust is established is always a challenge. What works for one patient may be offensive to another.
Respecting cultural boundaries and understanding social norms within different cultures are paramount to clinical practice in Australia. One patient will kiss your hand while another will refuse to shake it and send a female member of their family to shake it instead.
Flexibility, likability, approachability, there is no clear personality trait that makes you successful as a clinician. Listening is the introductory key and good observation skills are necessary. Observations of subtle body signals are critical. New work systems limit our visual observations with the need to do data entry on our initial patient communications. As clinicians, if our eyes are on keyboards and monitors, sometimes and somehow this can be the point of fragility where we lose connection with our patients.
When an eye test becomes inconsistent what do we do? Reschedule, reanalyse, anticipate negative responses as a mark of consistency? In my early years, I would wonder why the patient would chat to the 62-year-old secretary and divulge so much private information in the waiting room and then give me fragments in the consulting room. Connection, then trust.
A patient needs to trust you to hand over their vitals: a full history and full reason for visit. The ethos of the late and great Brien Holden was to try and help those in most need. His ethos resonates in my mode of practice, particularly with the highly anxious patient. Our time management needs to allow for patients with unexpected and challenging behaviours. Patients can present with major debilitation, feeling their way with new low vision, or, if ridden with anxiety, observing the practice from a distance to anticipate the courage to walk in at the right moment when they can catch our complete and undivided attention. The ultimate work satisfaction is when an extension of your service, skill or manner turns an anxious patient into one who is delighted and appreciative or your service and expertise.
We generally speak of consolidation time for the patient following a consultation, however it is just as important for practitioners to absorb their reaction to difficult case presentations and develop unique strategies for that patient.
Unhappy patients need to feel you are doing all that is necessary to help them with their problem over time. Any compromises on cost or time or even patient choices need to be clearly understood. Delayed referrals, personal carers waiting for a time frame to suit their needs and patients with complex health issues need prompts and close monitoring because delays can result in poor treatment outcomes and we may be partially responsible.
While there are many types of, and reasons to be, a ‘reluctant patient’ this article focuses on patients who do not want an optometric consultation, but are required to undertake one to satisfy the needs of a third party. Their circumstances for being in your consulting room are out of their control. These are situations where you need to be one step ahead and have alternate strategies for when the patient steps up the gear of reluctance. This article explores three cases.
Selective mutism is defined as an anxiety disorder in which a person who is normally capable of speech does not speak in specific situations or to specific people.1 It is most common in the age group three to eight.1
In the optometry clinic, while working as a locum, I had the opportunity to examine four-year-old identical twin girls. They had attended the practice four weeks previously and were asked to attend for review. Despite having an outwardly normal appearance they were unable to offer any verbal communication. The previous optometrist had recorded that they were unwilling to talk and needed a retest when mum could negotiate a suitable reward (maybe an ice-cream) for their participation in the eye test procedure.
On greeting, both girls were shy with no up-gaze eye movement to greet me or acknowledge my presence. They fed off each other in that when one reacted shyly, the other ensured her reaction was matched proportionately. The consultation was going to be a challenge.
The ice-breaker came when we began the eye test with drawing. This was done on a bench seat in the waiting room area with mum and me sitting on stools while the twins perched on the taller bench seat.
“Let’s just draw pictures for fun,” I suggested.
Four people were invited to the task.
- Myself as the initiator
- Twin one – first born (taller, heavier build)
- Twin two.
We drew a circle, a square and a triangle, then progressed, adding detail and aligning these shapes to form a house with two windows and a central door (Figure 1).
Figure 1. Illustration of the twins' mutism ice-breaker task
We established handedness, penmanship, alignment awareness, willingness to participate, willingness to exceed task expectation, alertness to other twin and feedback from mum and any sort of clumsy behaviour. The girls were very clever and great with the drawing task.
We made a move to the consulting room. We progressed to colour vision with a cotton bud used for identifying target. Stereopsis followed, again using pointing with animal targets and most adult targets were also achieved. We also used the order of four people with which they were familiar.
Interestingly the child on the consulting room chair was the more frozen one. The child sitting on the stool next to mum was the more active participant, discreetly whispering visual acuity targets in mum’s ear. We rotated seats so that the other twin was also given the opportunity to indirectly participate in the visual acuity task. Fortunately, mum was receptive to her role as relayer of speech whispered into her ear. I had to play unaware and plead for an answer. The other twin was making a mockery of me as she gave all the correct answers to her mum.
Distance visual acuity was measured as 6/18 line at three metres, and later interpreted as 3/18 or 6/36. The visual targets were observed with ease and without squinting or compensating behaviour. We were unable to refine distance acuity on the day, and determining that it would be too challenging to push for a further eye test at that stage, decided to reschedule for one month later.
I needed to do my own research and adapt a comprehensive analysis of their vision to their mute behaviour pattern.
Mum was quite disappointed at her daughters’ lack of vocalisation despite the promise of ice cream. The children remained shut down in verbal communication for the full duration of their consultation. Even on goodbyes there was no attempt at eye contact, a hand wave or gesture of achievement.
I offered the following strategies to mum:
1. They would both benefit from short term separation intervals for one on one interaction with other family members and relatives.
2. Mum needs to gauge all aspects of their development more closely, individually and without the other twin’s awareness.
3. Positive re-enforcement for verbal communication with new people.
4. Exposure to varied situations, particularly involving children of a similar age group, such as play groups.
5. Referral to a child psychologist for a better analysis of their behaviour pattern. This was in the pipe-line but mum was doubtful that it was necessary at this stage.
I have encountered selective mutism before in older kids, teenagers and even adults. Managing these children is complex. We are unable to get a clear understanding of their life at home or their family dynamic. Children with selective mutism will essentially only communicate in a setting where they are comfortable, secure and relaxed. The condition may progress to adolescent years, with the child having great difficulty to initiate or respond to verbal communication.
Fearful scenarios can be birthday parties, school or family gatherings. Researchsuggests selective mutism is more common in bilingual or multilingual families.1 In the formative years (two - four), the child may have a varied pattern of exposure to different languages. Insecurity and temperamental inhibition become manifest in the child.1
Traumatic mutism is different in that the child is shut down in all settings and is something they cannot understand or process. Traumatic mutism may happen in response to witnessing death.
Social anxiety syndrome is where a child feels uncomfortable being introduced to people and is scared of teasing or criticism. Other behaviour traits are fear of being the centre of attention, perfectionism (fear of making a mistake), shy bladder syndrome and eating issues (fear of eating in front of others).
Treatment for selective mutism is urgent.2 Negative ramifications and ingraining of behaviour patterns can occur. A child will not simply grow out of it. Mutism of more than four weeks needs referral to a general practitioner and in subsequence, to a suitably qualified child psychologist. The quicker the child is treated the better the response to treatment.
Ommatophobia (also known as ommetophobia) is the fear of eyes. It is an expanding area which encompasses components of eye tests and includes the diagnosis of eye disease.3
Ommatophobia may be as simple as a reluctance to touch the eye and can have little impact in an asymptomatic patient. However, it can also be complex in that a patient requiring urgent care is crippled with fear regarding presentation.
Hyperchondria is the stubborn belief that one is healthy when medical evidence suggests the presence of illness. This is not to be confused with hypochondria which is an anxiety disorder where the individual worries about having a serious illness borne out of misperception.
Cyberchondria is a new term that refers to the individual who has researched a medical condition on the internet and is convinced they are a sufferer.4 This is categorised as a hypochondrial disorder as the person manifests a mental anxiety state attached to it.5 In optometry, the patient to approach with utmost care is the one with a family history of unknown blindness, sporadic rare eye disease or those that have encumbered detailed knowledge from an advanced sufferer of a particular eye disease. Their translation of its impact on their eyes can be remarkable. The choice of words in detailing and further conversation is important. Restrict use of the term blindness, and offer ‘reduced vision’ instead.
Occasionally the fearful patient will choose not to disclose the full picture about their specific fear or they will cover it completely and see if you care enough to dig deeper into their history or state of mind. Some will meet you half way or even be ambiguous about certain details. Refusal of dilation, refusal of tonometry and or refusal of tests (e.g. related to germaphobia) needs to be documented and it needs to be conveyed to the patient that this information will be on their files.
Requests by patients to have certain disclosed history omitted from files (e.g. HIV+) is at the discretion of the eye care practitioner. This is dangerous territory if the patient were to commence any litigation procedures.
Other fears to be aware of are:
- Fear you will judge a choice they have made, e.g. the decision to continue driving despite poor vision
- Fear their partner will find out about a visual deficit
- An assault victim may fear you will inform others
- Fear of failing the standard for recruitment to Police or Armed Services
- Fear of punishment for not reporting, such as a situation where a child does not report eye trauma or vision loss to a parent.
Experiences I have had as an optometrist include keratoconus patients who fear going blind, contact lens patients who fear touching the sclera; relatives of blind patients who fear diagnosis of an impending ‘concealed’ eye disease; concealment of a retinal condition/low vision in an arranged marriage situation; and general patients who fear equipment, such as a green fixation light in retinal camera and ‘puff ’/noncontact tonometer.
The vasovagal response may become apparent in some anxious patients. A trigger for the response may be extreme emotional distress at the sight of blood5 or even a high resolution retinal image (Figure 2). Some patients will enjoy the detailing while others will look away.
Figure 2. Large screen computer with highly magniified retinal images
As health practitioners, we become accustomed to frequent repetition of certain eye test procedures and are so closely focussed on eyeballs that we switch off to what is happening to the rest of the body. However, I have had patients faint in the consulting room chair when the response has made them pallor, sweat and experience a drop in heart rate and blood pressure. Often, in this circumstance, the patient is silent or non-responsive in a verbal sense and this is easily misinterpreted as consent to proceed.
The vasovagal response may present in some patients. After the fainting episode, the patient is apologetic and will self-claim that they were unable to control their response. Words of reassurance and a consoling nature are critical to avoid the patient becoming upset. It is recommended that the consultation does not proceed if the patient has had a fainting episode. The recovery may be transient and further anxiety issues may surface. Alerting staff, assisting the patient in communications and transport are imperative. Details of the event must be recorded in your notes. It is recommended that the patient report one to two weeks after the event to analyse results thus far. Reassurance measures (repeat of simple tests for example) are needed to give the patient confidence and trust in your clinical skills. Alternative avenues may need to be explored to complete the rest of the eye test without the patient becoming anxious about a specific procedure.
In the event that the patient decides to withdraw from further care, it is necessary to document this decision in your notes along with any statements the patient makes to you. This is important in case the patient develops an eye condition – you as the optometrist may be responsible for not resolving their fears or referring to a GP to help them seek psychological counselling for their unresolved fears about resumption of standard eye care.
DRIVING ASSESSMENT FAIL
In Australia, every driver has the duty to surrender their licence (or licensing standard) when their vision does not meet the driving standard.6 Unfortunately, some drivers resist or deny the need to do this.
Patients can present in an agitated state when forced to have an eye test, particularly if they have recently been diagnosed with a condition such as ‘diabetic’ on their drivers’ licence authority form. They may not have come to terms with their newly labelled condition as they may be visually asymptomatic. Owners of heavy vehicles, large buses, limousines and taxis have made considerable investment to the business of driving and they will fight for their right to drive even if their vision is well below standard.
Optometrists and patients with below standard vision need to understand and respect what is required of both parties. Patients who have been denied a signature from their previous optometrist will wearily sit through another eye exam in the hope of a favourable outcome on a second or even third attempt.
Behaviour patterns can vary from bullying manner, short temperedness and hostility to courteousness and overfriendliness. Regardless, the licencing authority form will eventually surface, occasionally brought in as an afterthought, and even by a third party (partner) requesting “just a signature” once the inferred friendship has been established.
The fact that your patient may never have had an accident or a concentration lapse while driving is not credited as a ‘pass’ standard. Neither is there any legal requirement on their part to disclose details of any previous accidents or events that have occurred while driving. Honesty and disclosure of relevant information is contralateral thinking for a patient in a compromised outcome situation.
In all cases, whether the patient is new or old, it is best to establish precise visual acuity measurements, even across many different sets of spectacles as some may no longer be suitable.
Using number targets for one eye and letters for the other eye can help where visual memory is interfering with a true visual acuity score. When things are starting to look out of favour for the patient, pay attention to the time taken for response as you can use this response speed in your explanation about ‘delayed response/extended thinking time’ in a driving scenario.
The three seconds per letter to pass guidelines and degree of squinting should also be noted. Furrowing of the brow line and other compensating postures should be recorded as this can be analysed in your communication of test result.
Ensure that the distant dominant eye is established and the reasoning and foundation of dominance score is understood by the patient. The relative difference between the two eyes needs to be established and once again clearly understood by the patient, particularly if there is a brightness difference or suppressive behaviour pattern observed. In assessments to drive for commercial drivers, there is also an important emphasis on the non-dominant eye in analysis.7 If the dominant eye is temporarily injured (e.g. a foreign body causing lacrimation and blepharospasm) it is important to know that the driver is still able to manoeuvre their vehicle without hazard to others.
The attitude of wearing protective shield style sunglasses would greatly decrease the risk of an episode of an airborne foreign body. Older experienced drivers are inclined to favour wrap style glasses and understand the obvious benefits to the driving task with the continuous wear of sunglasses. Sunglasses are also useful in minimizing evaporative dry eye caused by airflow on the driver’s face from the air conditioning system or natural air flow through window down driving. Your patient’s response to “do you wear sunglasses while driving?” will give you an idea on their understanding of protective aids and their coping strategy for disability glare and evaporative dry eye.
There is opportunity for an experienced heavy vehicle driver with new vision loss to continue driving heavy vehicle standard at the discretion of an examining ophthalmologist and specified conditional situations, e.g. day driving, restricted speeds and localities and rest break specifications. The attitude of the driver also needs to be evaluated. This is a difficult area if it is a new patient.
I have had driver’s licence authority forms completed by a patient in the vision section, claiming that the general practitioner filled it in. If you receive a form that has the first box already ticked without a VA score, this is a signal the patient has taken the liberty to nominate their preference. A form presented with already ticked boxes without scores or signature is an invitation for a challenge. Ensure that already ticked boxes are addressed appropriately. I generally proceed with the eye test, make my own conclusions and then proceed to fill in the form and only write on the form if the patient is in agreement with my conclusions.
A second appointment may be necessary to validate visual findings on day one, as or anxiety affecting the ‘fail’ result. It is recommended that specific error scores are recorded. If there is any ambiguity about the score on the initial eye test and the patient is looking for an improved result on any subsequent vision score test, the actual error score may be used in analysis.
The driver’s licence authority form needs to be handled with care as any errors or misprinting can cause confusion for the patient and the assessor. Any negative result needs to be discussed with the patient and the form is best left incomplete until all avenues are explored for a satisfactory pass. Cataract surgery, YAG laser capsulotomy, diabetic laser, intravitreal injections and many other ophthalmological interventions may substantially alter a below standard vision result. This opportunity needs to be clearly outlined to the patient. A patient may refuse initial referral to an eye specialist but may return for later referral.
There is also the opportunity to discuss down grading the licence category should the patient no longer need the original licence class. It is best to allow some consolidation time when the patient is somewhat overwhelmed with a result. Where the final visual acuity relies on a new spectacle make, to avoid legal loop holes, the form should be signed on spectacle pick up.
ASSESSING FITNESS TO DRIVE: LATEST EDITION
In August 2016 the National Transport Commission released the latest edition of Assessing Fitness to Drive, which contained the following two changes:
- A commercial licence will be reviewed two yearly instead of annually.
- Significant field loss (four contiguous spots) in the central 20-degree radius of fixation means the driving standard is no longer met.8
Repeatability scores, validation in a real-life driving scenario and interpretation of a central scotoma to a patient may prove to be yet another challenge for eye health practitioners.
|Esther Euripidou achieved her Bachelor of Optometry Honours in 1987. A clinical optometrist with 30 years in private practice at various eastern Sydney locations, she is particularly interested in developing strategies to deal with anxious patients.|
1. Selective Mutism. (n.d.). In Wikipedia. Retrieved November 22, 20016, from https://en.wikipedia.org/wiki/Selective_mutism
2. Shipon-Blum E., Smart Centre Selective Mutism Anxiety Research and Treatment Centre. www.selectivemutismcenter.org/aboutus/whatisselectivemutism(Pennsylvania)
3. Vasovagal syncope. www.mayoclinic.org/diseasesconditions/vasovagal-syncope/home/ovc-20184773
5. Cyberchondria. (n.d.) In Wikipedia. Retrieved November 2016, from https://en.wikipedia.org/wiki/Cyberchondria
8. Reviewing Assessing Fitness to Drive Summary. August.2016. http://www.austroads.com.au/driversvehicles/assessing-fitness-to-drive/2016-review-outcomes
Listening is the introductory key and good observation skills are necessary