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Current situation
When fitting a patient with contact lenses for the first time, the optimum lens is chosen with the accompanying solutions and case if required. Following instruction on lens application and removal, in addition to appropriate hygiene practices, lens wear and care, the patient is released from the practice in the hope that they will faithfully follow those instructions. The reality is quite different, with non-compliance in some areas of lens wear and care being unavoidable.1
Non-compliance takes many forms, and it is not always deliberate, and often the patient is unaware of their errors.2 Appreciating that non-compliance is very common (Table 1) is an important mind set when embarking on a contact lens aftercare appointment and striving to save patients from themselves. Influencing the patient back to using correct procedures is a challenge. First, the ECP must uncover the areas of non-compliance through careful questioning. Secondly, the patient must be persuaded to change their habits and non-compliant behaviours with the promise of great success in lens wear. A range of contact lens aftercare scenarios will be discussed with methods of correction that use the principles of influence and persuasion.
The work of Cialdini et al3 reveals six fundamental principles of human behaviours, and awareness of these helps the ECP to employ subtle changes to patient management advice that can make the patient more receptive and more likely to do the thing suggested.
There are six universal principles of influence and persuasion:4
? Liking
People are influenced more by people they like and who like them. ECPs who are liked by their patients are more likely to have their recommendations accepted.
? Authority
People defer to those with expertise and credibility to guide their decisions. ECPs should ensure that their qualifications and expert knowledge and training are known to the patient (eg certificates displayed on wall)
? Social proof
People behave in ways that are similar to others who are like them. Just as people seem to take more notice of what their friends say or advise them to do, use this to talk about advice in the context of what a similar patient to them has benefited from
? Consistency
Consistency causes people to act in line with previous commitments. A verbal or written commitment by a patient is more likely to be done - seek to use this when giving advice
? Scarcity
Opportunities appear more valuable when they appear less available. 'Appointments available today' is not as good a message as 'only two appointments available today' - the latter is more likely to generate action
? Reciprocity
Reciprocity obligates people to do for others what others have done for them first. Treating the patient to something eg giving them more time to discuss a concern, a mini-trial with contact lenses to see to try on frames, a starter pack of a new solution, sample pairs of daily disposable lenses, are all actions where the patient will feel more indebted to the ECP. This could manifest itself in the patient following instructions appropriately.
Liking
Given that people respond best to others whom they like, it is self-evident that efforts made to be a likeable ECP are well spent. Some people ooze likeability - they smile readily and are always seen to be in a 'good mood'. What about those where their natural demeanour borders on miserable? Human relations guru Dale Carnegie offers many principles to follow to enhance social interactions with people.4 These can be easily applied to the patient visit, and some of these are outlined in Table 2.
Authority
The principle of authority is seen in the way people respond to a person in uniform versus someone who is more casually dressed. A uniform generates an automatic response of 'authority' and superiority. The ECP role offering expert advice needs the stamp of authority and this can be achieved in a number of ways - some more subtle than others. Displaying certificates, diplomas and training achievements reassures patients that they are being seen by an expert and this filters through to the certificates displayed for other members of the practice team. Being smartly dressed also carries with it authority, one extreme may be a man wearing a bow tie, which is often associated with a professorial or academic standing.
While framed achievements offer 'background' evidence of an expert, all staff in the practice can also provide testimonials about each other. For example, an optical assistant telling the patient about the ECP's recent trip to a conference where all the latest information was discussed, reinforces to the patient that their practitioner is up to date. Equally, an ECP handing over to a colleague, perhaps for an instruction appointment, should also tell the patient the wealth of experience and expertise the member of staff has to help transfer both confidence and authority.
Social proof
Most people see a large queue behind one cash machine in a row of three where the other two machines have no people using them. There's a quick mental shortcut that is made to 'follow the crowd'. This can be utilised when managing patients. Phrases such as 'Busy people like you who are frequent flyers' and then insert the recommendation of choice, whether that is 'Choose daily disposable lenses for travel' or 'Find great deal of benefit from using comfort drops'. Qualifying the advice to be personal to the patient and that it is 'proven' advice among 'similar others' strengthens the impact. In the case of a patient who fails to turn up for an appointment, using the phrase 'most people keep their appointments and give us a call if they are unable to make it' helps to reveal the guilty party as an outlier which feels uncomfortable. As distinct with 'Oh don't worry, people are always forgetting their appointments here' and the message that 'It's okay to not turn up' this other phrase sends out. Social proof is useful when used to encourage appropriate behaviours.
Consistency
This principle of influence is a more subtle concept to grasp, and its subtlety is where the power lies. The basis is that once a person has made a public commitment to something, whether in writing or verbally, they are more likely to keep that commitment. An interesting example is appointment cards. If the card is written out by the staff, the patient is less likely to keep the appointment than if they have written down the day, date and time themselves in the practice on the card or perhaps entered it into their own diary or mobile phone. The use of informed consent is also helpful in this regard. When patients sign that they understand that the wear and care of their lenses is dependent on their following the recommended instructions, including the need to attend for scheduled aftercare appointments, the chance of compliance is enhanced compared with a patient not signing an informed consent form. It is straightforward to tell a patient that they must wash their hands prior to handling their lenses. To utilise the consistency principle, it is important to ask 'And will you always wash your hands prior to handling your lenses' and then waiting for the 'Yes, I will' from the patient as this signifies their public verbal commitment.
Scarcity
The classic example of scarcity in action is when a limited edition toy becomes popular at Christmas and stocks quickly sell out. Suddenly, the toy becomes the must find item. When something is scarce, people place a greater value on it. So how can this principle be applied to enhancing contact lens compliance? Scarcity can also hinge on what people stand to lose - in the case of the toy, not being able to get it in time and the child being disappointed/devastated. It is more natural for ECPs to reinforce what patients may gain from following correct procedures in contact lens wear, such as better vision and comfort (in the case of cleaning lenses). To put scarcity into practice, it could be better to present the advice in negative terms, such as, 'If you don't clean your lenses after every wear you'll miss out on comfort and vision'. Some patients are resistant to attending for aftercare appointments. Perhaps if they were presented differently, for example 'You'll need to book your next aftercare appointment now, as we only have a few of those appointments each week and I don't want you to miss out on being seen'. Also, 'If you don't attend for your next appointment, you'll miss the opportunity of trialling a new lens that we have limited access to this month'. Scarcity builds desirability and is a powerful tool.
Reciprocity
Most people feel obliged to return favours, such as one friend buys a round of drinks and the other friends take it in turn to do the same. This natural human sense of obligation is very strong. The 'gift' need not be material, it can be giving time and advice. Take for example, the errant long-term contact lens wearer who is unwittingly non-compliant with both case care and solution use. This is mainly due to the fact that the patient was first instructed over 20 years ago and has never been updated since. Offering the patient the opportunity to spend time with the contact lens hygienist to have 'an update' can result in the patient returning the favour by becoming more compliant with those new instructions.
Conclusion
The management of the contact lens wearer in practice is both challenging and dynamic. Not only are there the logistics of taking care of the patient's clinical needs, but the real test is talking to them! For the ECP to be effective, they must be liked, persuasive and agile in their word management. There are many ways to say the same thing, and several options for providing advice. True lens wear success comes from a patient wearing the best product used in the prescribed manner. Patients may well provide some tricky scenarios to deal with, and with human relations skills and the powers to persuade, the ECP rises to the challenge. ?
References
1 Morgan et al. An international analysis of contact lens compliance. Cont Lens Anterior Eye, 2011 vol 34 (5) pp223-8.
2 Efron N. The truth about compliance. Cont Lens Anterior Eye, 1997; vol 20 (3) pp79-86.
3 Martin S. Influence and the Science of Communication. www.academyofvisioncare.com
4 Carnegie D. How to win friends and influence people. Vermillion, 2006. ISBN-10: 0091906814.
? Sarah Morgan is an optometrist and staff development consultant
Table 2
Principles for enhancing social interaction
? Don't criticise, condemn or complain. When a patient is clearly abusing their lenses, it seems natural to be critical of their misbehaviour. This serves only to alienate the patient towards the ECP and should be avoided
? Give honest, sincere appreciation. The patient is in the chair - this in itself is a result and gives the ECP the opportunity to check on compliance and re-educate where appropriate. Always thank the patient for attending the appointment, as this provides the opportunity to keep them up-to-date with new advice and new products
? Become genuinely interested in other people. It can be staggering what discoveries are made from a few simple questions about a person. Their hobbies and interests, where they live, can provide countless possible connections - perhaps there is even a mutual friend or past-time. Patients respond well when they feel like their ECP 'knows them' as an individual, and more powerful recommendations can be made and put into context once some insight into their lives has been made
? Smile. Look in the mirror and check the natural position of the mouth. For some people, it is naturally upturned and almost a smile in itself, and for others, the mouth is downturned. Efforts to smile when greeting patients make for a welcoming and friendly beginning, which in turn is positive when the ECP may need to discuss corrective measures
? Remember a person's name. People who have developed skills for remembering people's names reap the benefits, as to a person, the sound of their name, according to Dale Carnegie, is the sweetest and most important sound in any language. Always use the patient's name when introducing them to colleagues, and not just 'this lady' or 'this gentleman' - be personal as this enhances likeability
? Listen and encourage others to talk about themselves. When getting to know a new patient, ask open questions so that they talk about themselves. Not only does this provide helpful information in their clinical management, but it also affects their attitude to the ECP making them view the ECP in a favourable light. It is important to resist the temptation to talk about yourself when there is common ground. Certainly share some information sufficient to make the connection, but allow the patient to take centre stage
? Talk in terms of the other person's interests. Always ask yourself the question, 'what's in it for them?'. When advising patients, in what way will they benefit from taking action? Perhaps they gain better comfort and vision were they to routinely rub and rinse their lenses following removal, or their gain could be reducing the risk of a serious complication which might result in loss of vision
? Make the other person feel important - and do it sincerely. The ECP is seen as the most important person in the consultation from the patient's perspective, and when the ECP can make a patient feel important the impact is very powerful. For example, the simple suggestion of offering the patient to try a new lens type or solution, and saying to them 'I'd appreciate your feedback, as you're very successful with your lenses, so I value your opinion'. Indeed, loyal patients can help to assess the performance of new products being evaluated by the practice