Diagnosis of an ocular disease is one thing. Convincing your patient to comply with recommendations for treatment can be quite a different challenge. While it may be tempting to rely on websites, brochures and apps to educate your patients about their eye health and motivate their treatment compliance, neuroscientist Dr Fiona Kerr believes the most powerful tool you have is you.
A recent retrospective cohort study in the United States found that around 25% of patients who received an anti-VEGF injection to treat nonproliferative diabetic retinopathy did not return for a follow up visit within the ensuing 12 months.1 Other studies have confirmed the same level of noncompliance for treatment of neovascular macular degeneration.2
It has been estimated that 60% of glaucoma patients will drop out of follow up in the first year of review…
It has been estimated that 60% of glaucoma patients will drop out of follow up in the first year of review, and almost half of diagnosed patients are reported to be noncompliant with their glaucoma therapeutics.3
It may be difficult to believe that as an eye health professional, you can turn these disturbing statistics around, however Dr Fiona Kerr says, “you should never under estimate your powers to do so”.
Dr Fiona Kerr is the founder of The NeuroTech Institute, which looks at the neurophysiology of interaction between humans, with and through technology. She has qualifications in cognitive neuroscience, engineering, psychology, and anthropology, and for over 30 years has studied the science and power of human connectivity as both a practitioner and then as an academic (Fiona is also an adjunct at Adelaide university and a research fellow at SAHMRI). She has extensively researched the neurophysiological impact of human interaction with each other and technology. Though she believes the two go hand in hand, she says the key to achieving patient compliance is personal interaction.
“When patients are asked what would increase their capability for treatment, they say treatments should be easier and more discrete; they want non-pill medications, less pills per day, and a better taste. And they want less stringent recommendations on how to take pills so they have greater flexibility across the day.”
While applying less stringent rules to taking medications may be one of the more viable options, Dr Kerr says the downside of allowing greater flexibility is that your patient won’t develop a habit… and this will make it more difficult for them to remain compliant.
Some clinicians turn to technology to help their patients create new habits – the use of a smart phone to remind patients to take their medications or monitor eye health for instance – however, Dr Kerr says this is only part of the solution.
“The trouble with apps for monitoring a patient’s health is that you’re only getting a snapshot of what’s going on and you’re not actually seeing if a patient is using the app properly,” she says. “There are also various examples of patients who cheat when they use apps. To close the loop in patient care, you need regular human interaction… Combine virtual and social interaction and you can successfully change ingrained habits and achieve life-long behavioural change.”
IT’S IN THE WAY THAT YOU USE IT
Dr Kerr calls the brain “a work in progress, able to be rewired depending on what we pay attention to”. The brain creates habits – or patterns – so that it doesn’t need to take in new data all the time. Habits automate the way the brain goes about activities, saving time and cognitive energy.
Will power is like a muscle – the more you use it, the better it gets, and it is critical to breaking a habit and replacing it with another…
Thanks to neuroplasticity – our brain’s ability to reorganise itself by forming new neural connections throughout life – it is possible to dispense with these old habits and acquire new ones.
When it comes to achieving patient compliance for new treatment regimens, Dr Kerr says the trick is to empower your patients to make their own decisions rather than dictating the need to do so.
“We all have an internal locus of control – if we feel someone else is dictating what we are to do, we will often experience what’s called cognitive dissonance, which drives us to do the opposite, even when we know we shouldn’t.”
Thus cognitive dissonance – the discomfort a person feels when their beliefs are inconsistent with their actions – can result in negative behaviour. Essentially, the patient refuses to comply with recommended treatment despite having been told that to do so will be detrimental to their health.
“If a person feels they have no control, they won’t follow your recommendations,” says Dr Kerr.
To avoid this, you have to make sure the person feels in control of the decision making process – and this requires human interaction.
“It’s critical to be face to face with people as it causes all sorts of electro-chemical connection and change. The neural activity it stimulates means you can identify whether they are feeling engaged with the decision making process or not, and you can also steer them in the right direction as the increase in their neural plasticity through the physiological changes that occur with warm interaction helps to create new structures that guide behaviour.”
Will power is another obstacle to achieving long term behavioural change and again, human interaction can make a difference.
“Will power is like a muscle – the more you use it, the better it gets, and it is critical to breaking a habit and replacing it with another as a person has to stick with it until the new neural pattern is established,” said Dr Kerr.
If a person feels they have no control, they won’t follow your recommendations
She says the upside to changing one habit is that the brain benefits in other ways as well.
“While it takes an average of 12 weeks to form a new pattern of behavior, in complex problem tasks even if you consciously adopt a new behaviour for three weeks, you will find you are better at problem solving than you were. That’s because in the process of pushing yourself to change the pattern of behavior instead of falling back on automatic pilot, your brain has become used to using more cognitive effort.”
INTERACTION, EYE LOCK AND SKIN CONTACT
Unlike using technology, when you’re face to face with a patient you can use your eyes and your hands to form a personal bond that will help you motivate their will power and change their behaviour.
While this is not news – we’ve all experienced the effect of a sympathetic gaze or a supportive pat on the hand in our day to day lives – Dr Kerr says there is now scientific evidence to explain the chemical reactions that are occurring. She says several things happen when you simply interact with people.
“Various subsets of mirror neurons fire within a sixth of a second, helping us understand and have empathy for the other person’s actions and intentions. Interestingly, one subset of mirror neurons exist only to pick up smiling and laughter, suggesting the human brain has been expressly hard-wired to help us connect and bond.
“Voneconomo neurons, (known as Spindle neurons due to their long dendritic connections across various brain regions), go off within the 12th of a second. Often called trust neurons, these are only evident in the brains of animals with long term, nuanced social structures such as humans, primates and elephants. They enable individuals to read and respond to those subtle signals – the more they fire when you interact with a person, the more trust you will have in them.
“Apart from this neural electrical activity, we get a rush of various chemical exchanges when we interact with people in a shared space, even when we are not looking at them directly. Known as dynamic resonance and synchronisation, we exchange hormones, endorphins, and other chemicals when we spend time in close proximity. This explains why we enjoy group gatherings, why moods lift or drop when people share an office, and why hormone cycles become aligned. It also explains why a patient wants to come and see you when they are worried.”
Retinal Eye Lock
Dr Kerr’s research4 has found that when a person is in a heightened emotional state including stress (allostasis), they will increase direct eye gaze with a trusted other, and when that person responds, ‘retinal eye lock’ occurs. Retinal alignment causes synchronisation of various areas of their brain, (predominantly in the right hemisphere) and alteration in the activity of the amygdala, altering affect. This is reinforced by physiological changes in the body which can occur within as little as five minutes. Increased levels of oxytocin for instance, promotes positive feelings, reduces anxiety and improves immune system activity, partly through decreasing levels of cortisol which also bring on feelings of stress and negativity. Known as neural coupling or interpersonal neural synchronisation, it is an alignment that is measured using an EEG cap covered with electrical sensors and hooked up to a brain scan.
“When you’re talking to a patient sincerely, with a warmth that shows you have their best interests at heart, the socio-emotional parts of your brain are firing quite heavily, and you’re changing the way their brain is firing as well by engaging the same areas of their brain through neural coupling,” said Dr Kerr. “The more neural synchronisation and warm eye gaze you have with your patient over time, the more you get to know a person and the stronger the bond becomes. Interestingly, the lag time between the two brains physically synchronising decreases over time. Eventually you get to the point where you’re able to pick up data from the other person very quickly with no lag time – with enough exposure you may even be able to pre-empt their thoughts and actions – as you do with a long term partner.”
Dr Kerr says when people won’t make eye contact, there is a reason they are avoiding bonding with you and it is important to work that out. “It may be that they are not ready to accept the situation and make the behaviour change needed, and one of the ways to avoid this is to minimise directly connecting with you. It may be because your manner is not warm or respectful, or too focused on technical logistics while they are still in emotional catch up phase. These are all reasons they may be fearful, anxious, or don’t want to take your advice.
Empathic engagement creates a difference in the way a patient will make a decision
“In this instance, it is important to consider other approaches. Ensure you are allowing them to work through the emotional shift of coming to terms with a medical condition, and never underestimate your power to change their brain chemistry as discussed. For some who are not ready, it can mean bringing up different topics of conversation, or engaging them in calmly looking at any relevant assistive technology together. Eventually you will find a point of connection that will enable a bond to form.”
Power of Skin
In addition to retinal eye lock, Dr Kerr said skin contact can be an extremely powerful way to change the neurophysiology of a patient and create a chemical cocktail for changing behaviour.
“While we know it empirically, scientific evidence is now mounting in support of the idea that touch having real therapeutic effects. Touch fires the c-fibres in the skin which are attenuated through emotional pathways before the stimulus reaches the brain. When administered by a trusted person in a caring and sympathetic way, touch can be more effective than regimens of drug treatments or even technical restraints when it comes to calming a person down.
“So, if you’re sitting with a long term patient and they’re worried and you put your hand on their arm, you will exchange a rush of extra chemicals. Sometimes, rather than letting words get in the way, this can be more powerful.”
ENGAGE WITH EMPATHY
Eye to eye and/or skin to skin interaction also facilitates a level of empathetic engagement with a patient that cannot be emulated via technology, and Dr Kerr says, this is critical to changing a patient’s behaviour.
“Empathic engagement creates a difference in the way a patient will make a decision. Not only does it alter their emotional state but it also has a physiological impact on their problem solving and judgement by changing the decision making pathways in a number of ways,” said Dr Kerr.
She said an eye health professional who communicates with empathy shows the patient they care and provides the patient with a feeling of support and connectedness. “When it comes to complex decision making, which is a critical part of compliance as we are constantly weighing up priorities in real time, empathetic engagement can encourage a patient to rationally explore the options.
“The patient’s focus changes massively – rather than thinking about what they want to do right now, they stop to think about the long term consequences of what will happen if they don’t comply with your recommendations. Empathic engagement changes what we take as relevant criteria with which to judge options. It increases the tendency to think long term and to take consequences into consideration. Thus patients make different decisions.”
“Another remarkable thing about our ‘plastic’ brain is that the practitioner’s brain also changes over time. When you start engaging with empathy you get better at picking up concerns and resistance, and you can steer people into changing their behaviour. The more you engage the socioemotional parts of your brain, the more active they become.”
“Patients feel more respected, they feel more able to voice any concerns they have regarding their ocular condition or medication, they have a greater sense of agency (regaining their internal locus of control) and their hope of improvement even increases, which assists general wellbeing. All of this better equips them to make decisions for themselves and commit to something effortless, which leads to greater treatment compliance,” said Dr Kerr. “The many benefits of technology can then be realised, including its value in helping to reinforce compliance with treatment schedules, makes routine communication easier and allows the patient to explore information relevant to their situation.”
The message? Combine your superpower for personal patient interaction with the smart use of technology, and you can not only improve cognitive capacity in both of you, but also assist in successfully achieving life-long behavioural change to bring about better eye health outcomes.
- www.healio.com/ophthalmology/retina-vitreous/news/ online/%7B6a28aca5-32fc-4742-900c-fb7f8633a14f%7D/ one-in-four-anti-vegf-therapy-patients-with-dmelost- to-follow-up?utm_source=selligent&utm_ medium=email&utm_campaign=ophthalmology%20 news&m_bt=2739966098489
- www.mdfoundation.com.au/content/around-20- 25-patients-who-receive-anti-vegf-treatment-are-lostfollow# sthash.ThOiIBVt.dpuf
- Jessica Chi, Achieving patient compliance: our role as educators, mivision issue 143, March 2019.mivision
- Neurophysiology of human touch and eye gaze in therapeutic relationships and healing: a scoping review. Kerr,F., Weichula, R., Feo,R., Schulz,T., Kitson,A. DOI: 10.11124/JBISRIR-2017-003549