Things That Slow Us Down
A vision test is the indisputable foundation of a good eye exam. Sometimes, it's the "make it or break it" factor that influences clinical treatment decisions. If any test is worth doing right, it's the vision test. For low volume practices, technicians can spend as long as they want to try and push the patient to see the smallest letters. In higher volume clinics, however, saving a minute on each vision exam is to save an hour at the end of a 60 patient day. But how can we do this without compromising test quality? Here are a few tips to help shave off those coveted minutes and move the patient to the next phase of the exam as easily as possible.
Tip #1: Intentional Phrasing
I can't tell you how many times I've fallen into the trap of handing the patient the occluder and saying "Ok, tell me what's the smallest letters you can see up there". Nine times out of ten, the patient will say "well I can see all of them but I just can't read them". Then I have to fake laugh as if that's the first time I've heard this incredibly funny and original joke before the patient regains concentration and actually tries to read whatever he can. I've found that the solution to this is change one simple word: switch "see" to "read". "Ok, tell me what's the smallest you can READ up there". I've found that this doesn't leave the patient any wiggle room for time wasting comments and they simply oblige by the request. If they can't read anything, they'll simply reply with "I can't read any of them". PERFECT. They've just supplied me with relevant and real time information to help me expedite this exam. Now I can just put bigger letters on the chart and repeat the question: "can you READ any here now?" This saves a lot of time and frustration. By the time you've checked your 15th vision that day, hearing "I can see but I can't read" is very testing to the will.
Tip #2: Subliminal Manipulation
The occluder, while supposedly self explanatory, is actually one of the most complex technological designs that humans have ever devised. Often, when handing a patient the occluder, they'll say "right eye or left eye". It's a 50/50 chance that you know what they're referring to. Some people mean "do i cover my right or left eye" and others mean "do i look through my right or left eye". No one knows and it takes too much time to figure it out. A great way to circumvent this scenario is to hand the occluder to them in the way that YOU want them to test. I always start with the right eye, so I will hand the occluder to them in their right hand and have them hold it up. If they ask "right eye or left eye first"...I don't entertain that question directly. What I reply with is "just like that" and motion with my hand to simply hold the occluder up to their face exactly like they're holding it. This way, there's no confusion, they don't flip it around trying to figure out what you mean, it's flawless. Subliminal manipulation can carry you very far in other parts of the exam. Another good example is the Zeiss Cirrus OCT. It has two chin rests. I used to instruct the patient by saying "ok, let's get started on the left side first", which means we're testing the right eye. Well about 50% of the patients thought I meant let's get started on the left side of their face first. So now I've adapted to saying "ok, let's place your chin on the left side of the chin rest right HERE" and I point to the half of the chin rest that I want.
Of course, the better way around this situation is to forget Zeiss and buy a Heidelberg. Disclaimer: I'm not affiliated with either company, I get no kickback or advertising dollars from stating my opinions. I'm just a person with 12 years ophthalmology experience and I feel that Heidelberg is a far superior product for a myriad of reasons: not least of which is the ease of patient understanding in how to use the test.
Tip #3: Lead Every Step
Even if a patient has been to the office a hundred times, it's still easy for them to forget exactly what the protocol is. They may see more than one eye doctor for different conditions and each office does things differently. While you're preparing to hand them the occluder, state what your expectation for the test is. "Ok, you can leave your glasses on, then hold this over the bridge of your nose". Or, "ok let's start with your glasses off then we'll check with them on again". Which ever way is your preferred method, lead with it. This way, by the time the occluder is in your hand ready to give to them, they've already completed 50% of the task of removing/putting on their glasses.
I also always recommend at least a small history before vision testing. This allows me to start on a line, or set of lines, that is relevant to the patient. If they saw 20/20 last time, I don't want to give them 20/80 and make them read all the way down. I'll give them something close to where they were last. If they come in saying my vision's gotten a lot worse, then I'll ask questions about how bad it's gotten and give them a vision test starting where I think those questions lead me to. If they say they can still see words on the tv but not as good as they used to, I'll give them somewhere between 20/70 and 20/40 to start. If they say they can't see anything but shadows, naturally I'll start with finger counting and see if there's anything beyond that starting point.
All in all, being just a very small step ahead of the patient in the exam is a great way to save time. Populations differ in various areas of the country as far as patient quirks. I'm based in South Louisiana and I've identified a hard set of data points that every patient is "at risk" of committing. Those points are expressed in this article. In a clinic I worked at in Florida, we had to ask patients their age. 98% of all patients would respond with how old they were going to be on their NEXT birthday, not how old they currently were. Even if their next birthday was 8 months away, this was their answer. I could never understand that, but it was a quirk with that population. Things may be a little different wherever you are reading this article. But the concepts apply. If you can identify general trends in hold ups during your exam, you can usually find a way to lead/subtly manipulate the patient into giving you the information you want with as little interference from distractions as possible.