American Academy of Ophthalmology Web Site: www.aao.org
Clinical Update: Eye on Eye Medicine, Part Seven
Out of Earshot: What Patients Say About Their Eye Care
For more than two decades, Derek Preece has been asking patients what they think about their ophthalmic care. “I have a good sense of what patients like and don’t like about what their doctors are doing,” said a senior consultant with BSM Consulting Group in Orem, Utah.
Yet what resonates most with Mr. Preece isn’t something culled from the more than 50,000 patient surveys in his database. Rather, it’s the memory of a chance observation in a doctor’s waiting room: Mr. Preece was jotting notes after having interviewed physicians and staff when an irate woman rose from her chair, walked over to the receptionist and said, “If you don’t get me to see a doctor right away, I’m going to walk out of this office and never come back.” Just then, the doctor entered the reception area and the woman stopped, midsentence, smiled and exchanged pleasantries with him. The moral of the story, said Mr. Preece, is that “patients will not complain to the doctor.”
Focus Shifts From Physician to Patient
Yet, when asked in focus groups, surveys and interviews, patients will readily express their grievances (as well as their praise). In fact, in the last 20 years or so, the body of literature that gives voice to patient concerns has grown, as researchers have begun delving into the minds of patients and asking how they feel about their medical care.
Interest in what patients think about their ophthalmic care has been prompted in part by the move away from physician-centered to patient-centered health care, according to a paper by Aerlyn G. Dawn and Paul P. Lee, MD, JD,1 in which they report on patient focus groups at Duke University.
Other motivations for hearing patients out include increased competition in the eye care market and the dramatic rise in refractive surgeries, which has drawn a growing number of patients to the field of ophthalmology for non-sight-threatening conditions.
Show that you’re listening. The resulting body of literature reveals that communication, and what colloquially is known as “bedside manner,” ranks high on the list of patient concerns. Interestingly, waiting room time, the complaint that so enraged the woman Mr. Preece observed, isn’t dramatically high on anybody’s list unless it’s excessive (beyond 20 minutes, and two hours for total visit). Waiting time is the most common complaint, but not the most damaging, Mr. Preece said. “The most damaging is: ‘My doctor doesn’t care, doesn’t listen.’”
For example, a patient might say, “My right eye is really bothering me, and it kind of burns.” Meanwhile, the doctor is already looking through the slit lamp and sees a corneal erosion or blepharitis, Mr. Preece said. “The patient wants to go through this long explanation about the fact that the condition may be the result of the makeup she wore, and the doctor, in a hurry, cuts her off and tells her what to do,” he continued. “If the patient doesn’t get to say everything he or she wants to say, then he or she feels the doctor isn’t listening. This comes across a lot in our surveys.”
Do We See Eye to Eye?
Honesty: The Best Policy
What do patients want from their doctors? The 38 patients in six focus groups at the Duke Eye Center rated honesty more frequently than other expectations, including interpersonal manner, physician’s skill, and logistics such as waiting room time. “The one thing I look for more than anything: honesty. I just want [the doctor] to be straightforward,” said one patient. The focus group patients, who represented a variety of diagnoses and a range of socioeconomic levels, also emphasized the importance of receiving diagnostic and prognostic information. And they wanted that information in clear language. Said one: “Give me a name [for what I have], what’s wrong with me, that’s why I’m here.”
Empathy: the best strategy. On the other hand, the patients weren’t as concerned about specific medical or surgical treatment recommendations the ophthalmologist may make. As Ms. Dawn and Dr. Lee write: “While most patients are not equipped to measure the technical quality of eye care, patients are fully qualified to evaluate their ophthalmologists’ communication style and level of caring.”
In other words, patients place a high priority on communication of medical information, explanation, listening and personal connection, rather than on the treatment itself.
It’s not that the treatment is unimportant, said Mr. Preece, it’s just harder to judge. “We all want two things from our doctors: competence and a caring attitude. But we judge them almost exclusively on the attitude. We have no frame of reference for competence.”
Barriers to Care
Cynthia Owsley, PhD, knew that older African-Americans don’t seek routine eye care as often as other segments of the population, and as a result they often have more advanced stages of disease when they finally do see a doctor. But she didn’t know why they stayed away.
“We wanted to find out in their own words their attitudes about what they perceived as barriers to eye care,” said Dr. Owsley, professor of ophthalmology at the University of Alabama in Birmingham. She found that inadequate transportation was the most frequently cited barrier, according to 119 participants in 17 focus groups.2 Patients also cited trust of the doctor and communication problems among the top reasons they don’t seek eye care. Said one: “The doctor leaves the room before I can ask questions.”
Still, most comments were positive, focusing on the high value they place on the role of good vision in well-being, and the importance of seeking eye care.
Physician, avoid assumptions. Dr. Owsley also conducted focus groups with eye care providers, 25 percent of whom were physicians of color. They identified some of the same perceived barriers to care as the patients—transportation and cost. “The one issue that the doctors did not emphasize but that older African-Americans mentioned a lot was the communication issue,” Dr. Owsley said.
“They may be aware of it, but it did not really come up in the focus groups. They don’t fully get the communication problem and its significance to the overall quality of care from the patient’s standpoint.”
That wouldn’t surprise Mr. Preece. “Most practices don’t really figure out what patients want,” he said. “They assume they know.” But they don’t, necessarily.
For example, complaints about hot or cold waiting rooms frequently appear in patient surveys. While waiting room temperature may be a minor complaint, it’s important to some patients, Mr. Preece said. It’s also easily remedied by adjusting the thermostat. “But you don’t know unless you ask,” he said. “You have to figure out what your patients really want from you and deliver that.”
2 Owsley, C. et al. Invest Ophthalmol Vis Sci 2006;47:2797–2802.