Good communication skills are at the foundation of the modern optometric practice. They contribute to a successful practitioner-patient relationship, to better healthcare but also to an increased cooperation between team members responsible for our patients’ well-being. The purpose of this article is to present general elements of patient-practitioner and inter-professional communication in the optometric practice.

Patient-practitioner communication

‘You must make the care of the patient your first and overriding concern’ states the first recommendation that the College of Optometrists (CoO) makes in their ‘Communicating effectively with patients’ document.1 This principle is of the utmost importance; however, without good communication skills, even the most skilful clinicians will fail to offer their patients the best care. Indeed, year after year, the annual report of the Optical Consumer Complaints Service lists that one of the most common causes for patient complaints is the quality of customer service. In addition, poor communication between practitioners and patients is one of the reasons mistakes occur in the healthcare system, including optometric practice.

Communication skills are at the core of healthcare practice and contribute to the ultimate goal of achieving the best care for our patients. Communication includes language, but also perceptions, feelings, empathy, honesty, collaboration and appropriate use of technology. In addition, beside face-to-face interactions, the practitioner should also be aware of other ways they send messages to their patients, including the appearance of their practice and team members. Effective communication also extends to patient education via educational brochures, telephone communication, handling complaints, patient surveys and follow-up systems. If communication is right, then our patients are more likely to feel satisfied, follow advice, be compliant to treatment and recommend the practice.

General elements

The following are key components in generating a good inter-relationship between clinician and patient:

  • A clean, neat and modern practice – very important as a first impression. Little things such as availability of drinking water and printed educational materials, short waiting times and the appearance of dispensary can play a crucial role in establishing patient trust.
  • Appearance of staff – along with personal hygiene, this will make a crucial impression.
  • Physical layout of the consultation room – enhances a permanent contact between the patients and practitioners, is also important.
  • Language.

Language

One of the most important elements in patient-practitioner communication is language. From the initial greetings and small talk, to gathering and transmitting information, language is a powerful tool that practitioners can use to get the patients on board. In addition, correct use of questions to establish reason for visit and patients’ history, will help to move the consultation forward. The language should also be appropriate for each patient. Although some individuals will be able to understand medical or optometric jargon, most of our patients will not understand specialist terminology and will rely on easy to process information in order to understand their diagnosis and management. ‘Ill-informed patients tend to neglect timely treatment which can lead to very bad – sometimes disastrous – outcomes,’ said Dr Sidney Eisig of Columbia University’s College of Dental Medicine in New York. The struggle is real; explaining medical concepts to patients is a skill that improves with practice and gets refined after every patient encounter. A few tips to help with communications medical jargon in lay language, include:2

  • Practice explaining various terminology to family and friends.
  • Ask the patient to repeat the instructions back to you.
  • Use analogies; cataract is often explained as looking through a ‘dirty window’.
  • Draw pictures to help patients visualise what you are talking about.

Most optometry textbooks emphasise the importance of eye contact when communicating with patients. Maintaining eye contact reassures the patient that we are paying full attention to their concerns and needs. In the ‘Practical Work of the Optometrist’ project (published in the ‘Communication Skills Development Portfolio for Eye Care Practitioners and Trainers’, a collaboration between the College of Optometrists and King’s College London) it has been shown that removing eye contact is perceived by the patients as a negative gesture and triggers various responses, including a halt in conversation and making gestures to attract the attention of the practitioner. It has been suggested in this document that withdrawal of eye contact can have a negative impact not only on communication but also on patients’ satisfaction.

Patience and honesty

Patience and honesty are also essential when communicating with patients. Optometrists have to be prepared to answer various questions, to explain certain points, as well as to listen to the patient’s worries and empathise with them. There has to be trust between the practitioner and the patient and this can be maintained only if practitioners and patients ‘have open and honest communication in the management process’.3 A study carried out in Nigeria explored the degree of patients’ honesty in front of their optometrist.3 The participants involved included patients and eye care practitioners (with minimum five-years’ experience) from various age groups. Many of the patients included in this study admitted to lying to the doctor by either leaving important details about their condition out (eg time of onset) or about medication they had used previously. Some patients also complained that practitioners ‘do not give their patients enough time to explain their complaints before interrupting them’.3

Optometrists cannot control whether a patient lies to them or not but they can make sure that the patient is not put in a situation where they feel that they cannot trust the optometrist or fully open up to them about their health problems. The conclusion of this study was that honesty ‘should be the rule of thumb in the doctor-patient relationship, where communication is key’ and that ‘both parties should relate truthfully with each other’.3

Empathy

It has been demonstrated that, as we become more accustomed to medical practice, we tend to lose empathy.4 ‘The patient will never care how much you know until they know how much you care’, stated Terry Canale, the vice-president of the American Academy of Orthopaedic Surgeons. Indeed, all our patients entrust their health to us. When they arrive to our practices, they have lots of uncertainties and apprehensions. Empathy, defined as ‘the ability to understand and share the feelings of another’, plays and important role when trying to build trust, to calm anxieties and make the patient adhere to management. The practitioner should acknowledge and validate patients’ feelings. He or she should make the patient feel understood and justified in their behaviour and also explain how their management plans are chosen for their individual circumstances. All these can be done with the help of tools such as mindfulness, increased awareness of the patients’ verbal and body language and refraining from judgement.5

It was recommended that affective communication skills should be taught during undergraduate taught programmes.6,7 Gross et al 8 also emphasised that students should be taught communication skills that ensure ‘empathetic, easily understood, culturally competent and compassionate’ interactions with patients.

A video that presents the importance of empathy in patient care went viral on YouTube and can be watched here: https://youtu.be/cDDWvj_q-o8.

Collaboration

The practitioners should always encourage the patients to voice their concerns, thus contributing to a collaborative communication. In this way, practitioners can avoid making recommendations based on general assumptions and ignoring the individuality of each patient. Ways to ensure individuality include addressing the patient by name, personalising the conversation, encouraging the patient to express their own concerns, listening actively and acknowledging what the patient says, informing the patient about management and always addressing the patient, even when they come with their carer (adapted from College of Optometrists’ Guide to Communication, Topic 6: Understanding patient concerns 1 – treating the patient as an individual). In addition, the results of tests as well as management plans should always be discussed with each patient, taking into consideration expectations, outcome preferences, risks and costs, thus sharing management responsibilities with them.9

Education

Patients’ education is also a very important element of communication. Often compliance to a certain management plan is linked to the level of education that the patients receive from practitioners. This starts in the waiting room by having available a large variety of printed materials; it then continues in the consulting room though verbal advice and providing written instructions. Finding out what are the patient’s beliefs and correcting any wrong information is also part of education. Lectures, open days, video and audio tapes and online materials, all can be accessed and can contribute to informing our patients about their conditions. The choice of one method or another depends on the patients’ demographics and access to various technologies.

Communicating with patients training

Not everyone is born a good communicator; these skills can be learned through a good understanding of the main concepts, practice, motivation, self-awareness and monitoring.

Currently, there are no GOC requirements for specific undergraduate communication skill courses. Nevertheless, providing our students with such skills is very important. One method, that is quite successful in helping students develop their communication skills and prepare them for various clinical scenarios, is role playing. The effectiveness of this method was tested in a pilot study where students ‘were recorded during encounters with actors.10 The actors portrayed five common clinical scenarios that included retinal detachment, age-related macular degeneration and various ocular complications related to the use of contact-lenses. Students who took part were then split in to two groups. An enrichment group, who experienced all five clinical scenarios, received immediate instructor feedback and had the opportunity to view their video-taped sessions and a non-enrichment group who only did the first and last clinical scenario, did not receive any instructor feedback and did not have the opportunity to view any video-taped sessions. The results from the study showed that, despite all the students showing improvement from the first scenario to the last, the performances of the enrichment students, were ‘rated more improved’ compared to those non-enrichment students.

The use of videos and role-plays, as well as being effective in developing the communication skills of students, is also considered effective by qualified optometrists.

Another way that universities try to offer communication skills practice/training, is by providing hospital placements. These are very useful as they allow the students to be exposed to patients with various pathologies. Students can gain a lot from these

experiences by observing how practitioners communicate with patients with various pathologies and backgrounds. They can witness various type of responses and interactions and use these observations to modify and improve their own communication skills.

Inter-professional communication

A good proportion of our patients are co-managed by a team of two or more healthcare professionals. Most optometrists do co-manage patients with ophthalmologists or general practitioners (GP). When the patient needs a referral, it is invaluable that the information provided by the primary eye care provider is comprehensive. Similarly, when the patient is referred to the optometrist by their GP, it is very important that the optometrist gets a complete set of data regarding that patient and is able to translate it into the best possible care. Nevertheless, it has been reported that communication sometimes breaks after the referral was made and feedback on patients’ progress is not always received.

The Royal College of Ophthalmologists and the College of Optometrists have, since 2015, a joint agreement on sharing patient information and providing optometrists with feedback after referral.11 However, it is still reported that this is not always the case. The report on patients is sent most of the time to their GPs by the hospital’s electronic system that automatically generates such letters. These electronic systems are not built to send letters to the patients’ optometrists.12 In order to be able to send feedback to optometrists, ophthalmologists need to make this part of their routine practice and give special instructions.

Communications with other professions is mostly performed through referral letters. A good referral letter will allow an optometrist ‘to triage the referral effectively into the right specialist clinic in the most appropriate timescale’.13 Therefore, it is important that this document receives careful attention as ‘poor referral letter writing is seen as a significant reason as to why ophthalmologists are reluctant to work with community based optometrists’.13 The College of Optometrists recommends a good referral letter should contain all the necessary information, such as relevant details and findings from the patient’s eye examination, reason for referral, details of discussions with the patient as well as the level of urgency. A good article on interprofessional communication by Whitley published in the Review of Optometry 14 also suggests that, when writing referral letters, practitioners should implement the 7Cs of business communication:

  • Conciseness – short and to the point referral letters.
  • Correctness – use good grammar and give accurate information.
  • Clarity – write information that is easy to follow and understand.
  • Completeness – include all the essential elements.
  • Consideration – for the receiver.
  • Concreteness – use specific and confident language.
  • Courtesy – strengthen professional relationships.

Another issue is the communication with patients’ GPs. Difficulties are encountered in cases where practitioners do not have established relationships with GPs within communities. As the belief that optometrists only deal with eye conditions still exists, it is important that practitioners reach out and outline their expertise to the community’s healthcare teams. If GPs refer non-urgent issues to community optometrists, the patients will benefit by receiving attention much sooner than if they were to be referred to a hospital and wait for weeks, if not months to be seen by an ophthalmologist. An interesting study performed by Storey et al in 2016 15 looked into the effect of written communication between an ophthalmologist and a primary care physician on patients’ adherence to diabetic eye care. The results of this study demonstrated that written, two-way communication between the two categories of healthcare professionals was associated with increased adherence to follow-up eye examination. This one example can only emphasise the importance of team work when it comes to the patients’ best care.

Conclusions

Having a good patient-practitioner communication helps our patients in so many ways, from feeling valued and understood, to getting the best possible care and seeing that they are still in charge of their lives. Poor communication, on the other hand, can lead not only to patients’ dissatisfaction, but also to poor health outcomes, compromise of patients’ safety and could have even economic consequences.16 The importance of teaching communication skills to optometry students is well understood and, at the moment, all universities are offering specific modules that are customised to prepare undergraduates and postgraduates for a large variety of patients encounters in their future clinical practice. This training, however, should not stop at the university level and all of us should make sure that good communication skills are deeply engraved into our professional persona. 

References

  1. The College of Optometrists: Communicating effectively with patients. Available at https://guidance.college-optometrists.org/guidance-contents/communication-partnership-and-teamwork-domain/partnership-with-patients/communicating-effectively-with-patients/. Accessed on 16th June 2019.
  2. Petersen VM (2016). Say what? 4 ways to break down medical jargon to your patients. The Do. https://thedo.osteopathic.org/2015/11/say-what-4-ways-to-explain-medical-jargon-to-your-patients/ Accessed on 14th June 2019
  3. Ebeigbe, J. and Iperepolu, D. (2017). Disclosure of errors in optometric practice in Nigeria. African Vision and Eye Health, [online] 76(1), p.6. Available at: http://www.avehjournal.org/index.php/aveh/article/view/372/html. Accessed 4th February 2018.
  4. DiMatteo MR (1998). The role of the physician in the emerging health care environment. West J M 168: 328-333
  5. Leebov W (2016). Tips for communicating with empathy. The Hospitalist. July (7)
  6. Levine NR (1979). Identifying the teaching affective skills in optometric education. Am J Optom Physiol Opt. 56: 262-266
  7. Wallis NE (1992) What are the appropriate skills and knowledge required for the entry-level practice of optometry? Journal of American Optometric Association 63: 770-774
  8. Gross SM, Block SS, Engstrom S et al. (2008). Investigation of student self-perceived preparedness in interaction with patients experiencing psychological challenges. Optometric Education 34; 27-38
  9. Fong Ha J, Longnecker N (2010). Doctor-patient communication; a review. The Ochsner Journal; 10: 38-43
  10. Anderson, H., Young, J., Marrelli, D., Black, R., Lambreghts, K. and Twa, M. (2014). Training Students with Patient Actors Improves Communication. Optometry and Vision Science, 91:121-128
  11. The Royal College of Ophthalmologists (2015). Sharing patient information between healthcare professionals – a joint statement from The Royal College of Ophthalmologists and College of Optometrists. https://www.rcophth.ac.uk/2015/03/sharing-patient-information-between-healthcare-professionals-a-joint-statement-from-the-royal-college-of-ophthalmologists-and-college-of-optometrists/. Accessed 16th June 2019
  12. Optometry Today: Ophthalmologist says providing referral feedback in a ‘no-brainer’. https://www.aop.org.uk/ot/professional-support/health-services/2018/06/12/ophthalmologist-says-providing-referral-feedback-is-a-no-brainer. Accessed 16th June 2019
  13. Newsom, W. (2018). Top Tips for Writing a Good Referral Letter
  14. Whitley WO (2011). Interprofessional communication pearls for writing referral letters. Review of Optometry, April 5
  15. Storey, P., Murchison, A., Pizzi, L., et al. (2016). Impact of physician communication on diabetic eye examination adherence. Retina 36: 20-27
  16. Vermeir P, Vandijck D, Degroote S et al. (2015). Communication in healthcare: a narrative review of the literature and practical recommendations. Int J Clin Pract 69: 1257-1267