Compliance is not my problem

July 1, 2014

This morning, I saw a patient who came to our office complaining of discomfort, itching, and irritated eyes. She said she had done nothing different with her two-week soft contact lenses over the past three years. Her lenses were fogging up and would dry out after a few hours of wear. Upon examination, slit lamp biomicroscopy showed Grade 3 giant papillary conjunctivitis (GPC) in both eyes. Her lenses were moving excessively. Naturally, I assumed that this patient was non-compliant in her lens care. Doctors have been dealing with compliance issues with contact lenses since they were invented.

This morning, I saw a patient who came to our office complaining of discomfort, itching, and irritated eyes. She said she had done nothing different with her two-week soft contact lenses over the past three years. Her lenses were fogging up and would dry out after a few hours of wear. Upon examination, slit lamp biomicroscopy showed Grade 3 giant papillary conjunctivitis (GPC) in both eyes. Her lenses were moving excessively. Naturally, I assumed that this patient was non-compliant in her lens care. Doctors have been dealing with compliance issues with contact lenses since they were invented.

Doctors need to recognize that lens care is just as important as prescribing the right contact lens. We know the dropout rates vary between 15 to 30 percent depending on the study cited.1 We also know that our patients are not telling us when they have discomfort. We can assume they are not calling us when they have questions regarding their lens care. The result of this breakdown in communication may end in a contact lens dropout or even the loss of the patient to your practice. 

Make strong recommendations

We must take control of our offices and remember that lens care needs to be handled as a true recommendation, just like the lens choice we make for the patient. Patients often leave the doctor’s office confused about the lens care. They were not shown the process with the detail necessary to insure proper care. Technicians, who usually are the ones training the patient, often do not take this training seriously enough because they have so many other tasks to perform. We don’t ask if anyone else in the household is wearing lenses, so we can make sure the family has only one system to use and not mix solutions.2

So, how do we take back control and help our patients comply with our recommendations? First, we must assume that every patient will be noncompliant. If we anticipate this to be the case we can build a model to build compliant behavior.

We need to explain to the patient and demonstrate exactly how we expect him to care for his lenses. Talk about the time necessary to clean the lenses properly. Have the patient mirror the care to make sure he understands the various steps. Send the patient home with written instructions and a phone number to call if he has questions any time of the day. I have rarely gotten calls after business hours, but when they do happen, you create a bond with that patient that will last a lifetime. We have the patient go over his lens care at each and every visit. Remember that behavior that is not constantly being reinforced is soon forgotten.

Make sure the entire staff is on the same wavelength. You will lose trust and compliance if different people in the office give contradictory instructions. Take time in staff meetings to go over new products, and explain why you feel a product is more beneficial to the patient.

Have the staff members try products for themselves to see and feel the difference. Building trust is the most critical part of the relationship, and it requires that patients have a thorough understanding of the process. This trust is important in every recommendation we give the patient, whether it is treatment for an infection or for new eyeglasses.

Optometrists generally are afraid to give strong recommendations because we may feel pushy, or think the patient wants to choose on their own. This is usually not the case; the patient is coming to us and paying us for our recommendation. 

The strength of the doctor-patient relationship is built on the trust that is formed during the examination. The strength of this relationship, as well as patient satisfaction and success in lens wear, correlates directly to the doctor’s skill in giving instructions. In fact, a patient’s willingness and ability to comply are significantly influenced by the communication skills of the clinician. 

Studies have shown patients have higher expectations of success when they perceive their clinicians as skilled in information exchange and comfortable in personal interaction. I have certainly found this to be true and have found the time we spend with the patients to ensure proper care and follow through with treatments is rewarded with many referrals and loyalty.3

Identify the patient’s priorities

Remember that patients are not motivated by the same things as we as doctors are. We are highly motivated by good eye health, but our patients assume they have good eye health and are not that worried about that. We need to learn what motivated the individual in the chair-it may be the better eyesight her contacts provide, or maybe appearance. Find out the key to focus on and then talk about the need to do these steps to keep her wearing her lenses instead of glasses. 

So, let’s get back to my patient. After asking her how she took care of her lenses, she told me she uses that no-rub solution and just takes out her lenses and puts them in the case and refills the case to the top. After going through the proper instructions for lens care, including replacing the solution every day and rubbing the lenses, we decided to treat the GPC with steroids and antihistamines.

We will have her discontinue lens wear for a minimum of two weeks to allow the medication to take effect and put her in daily disposables to minimize the reaction to build up. She seemed to accept our recommendations and we will see her in a week.

Patients rarely attribute contact lens problems to poor compliance. When discomfort becomes an problem, they just abandon lens wear altogether and we end up losing the patient.  Make sure you are addressing these concerns in your practice.ODT

References

1. Rumpakis J. New data on contact lens dropouts; an international perspective. Rev Optom. 2010 Jan:17(1);37-42.

2. Geffen D. Lens Care Compliance. Optometric Economics. Jan 1992.

3. Meichenbaum D, Turk D. Facilitating Treatment Adherence: A Practitioner’s Guidebook. New York: Plenum, 1987.