I'd like to comment for just a moment on the thread that appeared recently on "Crybabies" which as I read it dealt with "dumb patients." I do have a designation I use on my chart, TDTT (Too dumb to teach), but I only use it about once or twice a year and its main purpose is to remind myself at future visits about any educational or understanding problems I had with a patient. Actually, I've learned that their aren't as many "dumb" patients as there are bad days for communicating with our patients. And I think this allows us as professionals to avoid getting exasperated with patients if you think of it as I suggest.
Today, for example, I had an Indian family, both Mom and dad, bring their 4 year, 10 month old in for her first exam. They were told at the preschool that the child may have some slight vision problem.
They brought no written report. This was the first exam, and they got my name from the phone book and traveled across the Susquehanna River from the West shore to the East shore (which if you know our area is for some like a trip to Mecca) to see me. Why? Because the ped whom they asked for a recommendation gave the number of an office that couldn't see them until April.
This could well have been the OMD's office that I send my surgeries to and that, nonetheless, still fails to return the occasional pathology referral I send them back to me when I consider they should. No, I don't use other OMDs because they are all worse. There is even one I tell patients I refuse to comanage with.
Let me get to the point! I start the exam myself with children this young and begin with a history and visual skills. The latter was not normal for distance and near acuities but was in other respects. As you know this probably rules out malingering or functional hysteria. The K reading (which I also do in these kids) revealed 4 dpts of with the rule astigmatism. This is one big hell-of-a clue for the rest of the exam.
Now, the exam ends and as you might expect my recommendation will be to wear glasses and unlike the majority of the simple myopes I want the child to wear these glasses a good deal of the time. At least until the refractive amblyopia improves from its presently equal 20/40 level OD and OS to better values which it will.
Okay, so now the explanation to the parents. First, those of you who examine Indian patients (Far East India) know that these patients and their kids are usually very intelligent as were these folks. Second, there is a cultural barrier. Indians do not put an American doctor on a pedestal. So you can imagine I was ALMOST a bit miffed when Mom questioned how I could find a problem when the preschool said it was "probably nothing too serious." Mom, I thought to myself, the reason you came to me is because I'm the expert, not the preschool.
But, I just chalked this up to what I've learned from other patients where the bonds of trust have not had time to gel. So I responded with the most convincing "I understand how you feel" that I could muster. Very professional.
Well, how come my daughter has this problem if neither my husband nor I wear glasses (I already know that because I had asked it during the history.) But, by the grace of Allah, I was prepared and asked, "How long has it been since either of you had your eyes examined." Jackpot. "Never.!!!" So you might not know if your vision could be improved? There was a slight pause. The parents were searching their computers for the best answer. However, I added because I had sensed what was a bit of concern over the fact that the child might have to wear glasses, that although she would, the problem was not too serious since for all we know both parents might have the same problem and they seemed to be functioning quite nicely.
As further evidence of the need for a Rx I handed the child (who had no problems with letters or numbers) a reading card and asked her to read some of the small numbers. She certainly did--at 5 inches. And when I moved the card to 14 inches there was silence.
But we're not done yet. I wanted to do a dilated exam and at the same time I might as well do a wet refraction to confirm my findings before prescribing the first lenses. Now, they need to return for this because the child is finished responding for this day. So, what does dad chime in. Well, it's pretty far to get here (probably 25-35 minutes) so can they GO TO ANOTHER DOCTOR WHO IS CLOSER TO THEM FOR THIS EXAM. I'm going to give him the benefit of the doubt and assume that he's confused and concerned about all we had discussed and temporarily insane.
I told him he could do that, but he'd have to pay another fee to whomever he chose for that procedure. I did not think at the time to remind him that he could either come back to me in the next day or two, but might have to wait until April to go, for example, to the doctor his pediatrician had recommended. But because time was marching on I did add that if the trip was too great, I could give him a written prescription after the next visit to be filled closer to home as long as he understood that I would need to follow the child closely for the next 2-6 months.
Now, even though I'm supposed to be an expert communicator, I saw the dad was somewhat confused about all this. So as he left I added something to the effect of I understood how much information we had discussed and that I'm only familiar with it because I do it every day. I asked him if and his wife all worked with computers. This is a no brainer as all Indians are fluent with computers and we had already discussed the fact that being on the computer a lot would not and had not hurt his child's eyes.
I then confided in him that when someone discussed computers with me I have exactly the same difficulty understanding what I'm told as he might be experiencing listening to me talk about eyecare. I suggested that he digest what I had just told him and his wife until the next visit. Then we could review as much as he wanted (perhaps after he researches eyecare on the INTERNET, I thought silently).
And I expect to see the family soon, although I write this while the dialogue is fresh in my mind and before the next chapter is played out.
There are a number of lessons in this tale. First, it's not "dumb" patients. People don't absorb what we tell them unless they are able to allow our message to penetrate their mental defenses. They have to trust us and like us before this happens. Establishing trust takes time, and if you do managed care you don't get paid extra for this time. Different cultures present additional barriers. It certainly would help if I had been able to speak a few words of Native Indian dialogue or known a bit about traditional Indian diet to bridge this cultural gap. It's my responsibility to establish these bonds, not the patients'.
Second, we need to see things from the parents point of view. We must realize that because patients don't understand eyecare, it's because they never had an incentive to do so UNTIL THEY SEE US. When this patient's mom said to me after I had completed a fun filled 50 minute evaluation of her child that she couldn't understand how anything could be wrong when the preschool had merely suggested a "minor " problem, she didn't mean to disparage my efforts. She probably was confused and concerned about the fact that her child could have what she must have perceived as a defect. At least that is how I could choose to interpret her remark.
One final comment. I do not write this story out of frustration REGARDLESS OF THE OUTCOME. I write it as a sort of diary for myself. My working days are spent practicing optometry or going to meetings learning about it and about others in my field. There is nothing I would rather do professionally than be in a SECO audience listening to Jimmy Bartlett, Ron Melton, Randell Thomas, or Dick Kattouf. Nothing. And there would be much less incentive to do so if I didn't have my interactions with patients. And these interactions would be less challenging if every patient swallowed everything I said as gospel. Just as boring as if everyone were clinically a 2.00 dpt. myope.
I want to write about the days I spend at the office so that I can refer to what it was like when my memories fade in my later years. And if my notes help others to sail the seas of outrageous encounters more tranquilly, that would be a real bonus. I'm grateful to my teachers, to my patients, and to the Optcom list for giving me the knowledge, the material and the audience to motivate me.
I consider myself blessed to feel like I do. And maybe I'm the one who's not too smart. But no one is going to accuse me of being a Crybaby.
Peter Dodge
Harrisburg, PA
February 2001
Copyright Peter E. Dodge 2001
Today, for example, I had an Indian family, both Mom and dad, bring their 4 year, 10 month old in for her first exam. They were told at the preschool that the child may have some slight vision problem.
They brought no written report. This was the first exam, and they got my name from the phone book and traveled across the Susquehanna River from the West shore to the East shore (which if you know our area is for some like a trip to Mecca) to see me. Why? Because the ped whom they asked for a recommendation gave the number of an office that couldn't see them until April.
This could well have been the OMD's office that I send my surgeries to and that, nonetheless, still fails to return the occasional pathology referral I send them back to me when I consider they should. No, I don't use other OMDs because they are all worse. There is even one I tell patients I refuse to comanage with.
Let me get to the point! I start the exam myself with children this young and begin with a history and visual skills. The latter was not normal for distance and near acuities but was in other respects. As you know this probably rules out malingering or functional hysteria. The K reading (which I also do in these kids) revealed 4 dpts of with the rule astigmatism. This is one big hell-of-a clue for the rest of the exam.
Now, the exam ends and as you might expect my recommendation will be to wear glasses and unlike the majority of the simple myopes I want the child to wear these glasses a good deal of the time. At least until the refractive amblyopia improves from its presently equal 20/40 level OD and OS to better values which it will.
Okay, so now the explanation to the parents. First, those of you who examine Indian patients (Far East India) know that these patients and their kids are usually very intelligent as were these folks. Second, there is a cultural barrier. Indians do not put an American doctor on a pedestal. So you can imagine I was ALMOST a bit miffed when Mom questioned how I could find a problem when the preschool said it was "probably nothing too serious." Mom, I thought to myself, the reason you came to me is because I'm the expert, not the preschool.
But, I just chalked this up to what I've learned from other patients where the bonds of trust have not had time to gel. So I responded with the most convincing "I understand how you feel" that I could muster. Very professional.
Well, how come my daughter has this problem if neither my husband nor I wear glasses (I already know that because I had asked it during the history.) But, by the grace of Allah, I was prepared and asked, "How long has it been since either of you had your eyes examined." Jackpot. "Never.!!!" So you might not know if your vision could be improved? There was a slight pause. The parents were searching their computers for the best answer. However, I added because I had sensed what was a bit of concern over the fact that the child might have to wear glasses, that although she would, the problem was not too serious since for all we know both parents might have the same problem and they seemed to be functioning quite nicely.
As further evidence of the need for a Rx I handed the child (who had no problems with letters or numbers) a reading card and asked her to read some of the small numbers. She certainly did--at 5 inches. And when I moved the card to 14 inches there was silence.
But we're not done yet. I wanted to do a dilated exam and at the same time I might as well do a wet refraction to confirm my findings before prescribing the first lenses. Now, they need to return for this because the child is finished responding for this day. So, what does dad chime in. Well, it's pretty far to get here (probably 25-35 minutes) so can they GO TO ANOTHER DOCTOR WHO IS CLOSER TO THEM FOR THIS EXAM. I'm going to give him the benefit of the doubt and assume that he's confused and concerned about all we had discussed and temporarily insane.
I told him he could do that, but he'd have to pay another fee to whomever he chose for that procedure. I did not think at the time to remind him that he could either come back to me in the next day or two, but might have to wait until April to go, for example, to the doctor his pediatrician had recommended. But because time was marching on I did add that if the trip was too great, I could give him a written prescription after the next visit to be filled closer to home as long as he understood that I would need to follow the child closely for the next 2-6 months.
Now, even though I'm supposed to be an expert communicator, I saw the dad was somewhat confused about all this. So as he left I added something to the effect of I understood how much information we had discussed and that I'm only familiar with it because I do it every day. I asked him if and his wife all worked with computers. This is a no brainer as all Indians are fluent with computers and we had already discussed the fact that being on the computer a lot would not and had not hurt his child's eyes.
I then confided in him that when someone discussed computers with me I have exactly the same difficulty understanding what I'm told as he might be experiencing listening to me talk about eyecare. I suggested that he digest what I had just told him and his wife until the next visit. Then we could review as much as he wanted (perhaps after he researches eyecare on the INTERNET, I thought silently).
And I expect to see the family soon, although I write this while the dialogue is fresh in my mind and before the next chapter is played out.
There are a number of lessons in this tale. First, it's not "dumb" patients. People don't absorb what we tell them unless they are able to allow our message to penetrate their mental defenses. They have to trust us and like us before this happens. Establishing trust takes time, and if you do managed care you don't get paid extra for this time. Different cultures present additional barriers. It certainly would help if I had been able to speak a few words of Native Indian dialogue or known a bit about traditional Indian diet to bridge this cultural gap. It's my responsibility to establish these bonds, not the patients'.
Second, we need to see things from the parents point of view. We must realize that because patients don't understand eyecare, it's because they never had an incentive to do so UNTIL THEY SEE US. When this patient's mom said to me after I had completed a fun filled 50 minute evaluation of her child that she couldn't understand how anything could be wrong when the preschool had merely suggested a "minor " problem, she didn't mean to disparage my efforts. She probably was confused and concerned about the fact that her child could have what she must have perceived as a defect. At least that is how I could choose to interpret her remark.
One final comment. I do not write this story out of frustration REGARDLESS OF THE OUTCOME. I write it as a sort of diary for myself. My working days are spent practicing optometry or going to meetings learning about it and about others in my field. There is nothing I would rather do professionally than be in a SECO audience listening to Jimmy Bartlett, Ron Melton, Randell Thomas, or Dick Kattouf. Nothing. And there would be much less incentive to do so if I didn't have my interactions with patients. And these interactions would be less challenging if every patient swallowed everything I said as gospel. Just as boring as if everyone were clinically a 2.00 dpt. myope.
I want to write about the days I spend at the office so that I can refer to what it was like when my memories fade in my later years. And if my notes help others to sail the seas of outrageous encounters more tranquilly, that would be a real bonus. I'm grateful to my teachers, to my patients, and to the Optcom list for giving me the knowledge, the material and the audience to motivate me.
I consider myself blessed to feel like I do. And maybe I'm the one who's not too smart. But no one is going to accuse me of being a Crybaby.
Peter Dodge
Harrisburg, PA
February 2001
Copyright Peter E. Dodge 2001
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