Patients' adherence to topical medical therapy for glaucoma is notoriously low. One way of improving their success is to communicate with them more effectively.
TIP NO. 1. FIND OUT WHO THEY ARE
“Tell me about you” is a good way to start every encounter with a new glaucoma suspect or patient. This request characterizes the beginning of a long-term, personal relationship that will determine if he or she does well. In videotaped observations and interviews with ophthalmologists and patients, my colleagues and I found that clinicians competently interpret test results but fail to develop an open dialogue designed to achieve the best outcome.1
Patients value and are awed by the technology of slit lamps, optical coherence tomographers, and perimeters, but they often are not included in the process. Are you speaking with a retired nurse, a truck driver, a grandfather, or a mother of the same number of teenagers that you have? Asking the patient who he or she is starts your therapeutic interaction on an equal footing. Moreover, your history taking and later explanation of findings and a treatment plan must take into account the difficulty anyone has with new and frightening information about his or her situation.
Find mutual interests or life stages you and the patient share so that he or she can see you as a partner, not someone on a pedestal.
TIP NO. 2. BE NONJUDGMENTAL
Allow that everyone has trouble remembering to take medicine for preventive treatments. I frequently share that I sometimes forget to take my daily blood pressure pill. Your admitting to occasionally missing a pill allows patients to acknowledge their trouble with drops.
In our research, my colleagues and I viewed videotapes in which ophthalmologists asked questions like, “You're taking your drops, right?” How would a patient respond except to answer yes? Instead, begin a dialogue by posing open-ended questions such as, “How are you doing with the drops?” Moreover, make glaucoma therapy a mutual decision. Let patients help to choose between eye drops, laser therapy, and surgery. Then, treat the decision not as their problem but your shared process.2
TIP NO. 3 . PRODUCE HOPE, NOT FEAR
Most glaucoma patients will not go blind3—an important piece of information with which to start the conversation. Next, you might say that those who lose vision are the ones who fail to come back for visits and do not follow the treatment program. It is worth noting that glaucoma changes slowly in most patients, so an occasional lapse is human and not a fatal error. You can then add, however, that regularly failing to adhere to prescribed treatment is not acceptable.
Generate appropriate concern, not fear. A patient paralyzed by fear from being told “you'll probably be blind in 5 years” will go into denial, stop coming back for visits, and discontinue medical therapy. On the other hand, do not leave patients under the impression that they have nothing to worry about. For example, if you choose not to start an ocular hypertensive patient on IOP-lowering drops, he or she must believe that the decision is only appropriate if he or she keeps coming back.
TIP NO. 4. PROJECT COMPETENCE AND CONTROL
You understand the options and choices. Never give the impression that you do not know what to do, because that will call into question everything in which the patient needs to believe. “If the board-certified, imaging- and instrument-wielding doctor is without options, what chance do I have?” the patient will wonder. Yet, every week, tertiary specialists see patients who are under the impression that their previous doctor ran out of options. If you are truly stymied, say, “In your situation, the best solution is to see a specialist who handles this problem all the time.”
TIP NO. 5. KEEP IT SIMPLE AT FIRST
You are juggling in your head field indexes, nerve fiber layer assessments, and risk calculations. Reduce your patient's level of terror, however, by keeping your explanations simple. On in-office videos, my colleagues and I recorded doctors saying, “Your fields are progressing.” The patients who heard this statement reported that they were happy that they were making “progress!”1
Instead, try making one of the following comments:
• “You do not have definite glaucoma now.”
• “Your testing shows no change from 3 years ago.”
• “You are doing just as well as we want in terms of
pressure and side vision.”
Then, ask the open-ended follow-up question, “What more would you like to know?” The patient will then tell you how much more he or she wants to know. Some would like to see the color disc images or graphs of stable fields. Show them but only after ensuring that they understand the main message. My office has a camera on the slit lamp and a flat-screen TV that can record and show patients and their families the optic disc, bleb, or lens implant. These images depict the actual situation and facilitate informed consent.
TIP NO. 6. ANSWER THE SAME QUESTION AGAIN
I was recently saddened by an e-mail message sent to a national glaucoma user group by a well-known glaucomatologist. This physician had “kicked out of the practice” patients who repeatedly asked the same questions or who came to the office with Internet printouts on glaucoma.
My colleagues' and my research on adherence shows that patients who seek additional information outside the office are more likely to be using their drops correctly than those who do not.4 Pharmaceutical sales representatives are taught that they have to convince doctors to prescribe the company's drugs by repeatedly drilling the same message. A senior marketing vice president commented to me that telling doctors the same “fact” 10 times makes it true, whether it is correct or not.
Not only should patients be permitted to ask the same question more than once, but in doing so, they are showing that the answer has not become part of their knowledge base. In our adherence research, my colleagues and I found that the patients most likely not to be using their drops were generally the ones with no questions. They wanted to leave the office and go back into denial as fast as possible (see Addressing Poor Adherence).
How do you know when your message has been received? It is not sufficient to ask, “Do you have any questions?” Ask the patient what he or she knows. I had the striking experience of asking a series of my patients to tell me what their glaucoma eye drops were doing that was good. Nearly 25% did not answer that the medication lowers pressure and thereby prevents them from losing more vision.
People cannot be expected to do the proper thing if they do not know what it is and why they need to do it. You may be thinking, “That is OK for you to say, Quigley, since you live in the ivory tower of academia and not in the trenches of real practice.” In this article, I am speaking as a clinician who sees five patients per hour for 9 hours on each patient day. You can still incorporate many of the aspects of interaction described in this article into the 8 to 10 minutes of chair time that each glaucoma patient receives. You will not use all of them at every visit, but cumulatively over time, you can use the whole package.
Harry A. Quigley, MD, is the A. Edward Maumenee professor and the director of Glaucoma Center of Excellence for the Wilmer Ophthalmological Institute at Johns Hopkins University School of Medicine in Baltimore. He is the author of the educational book referred to in this article, the royalties for which are donated to glaucoma research. Dr. Quigley may be reached at (410) 955-2777; hquigley@jhmi.edu.
- Friedman DS, Hahn SR, Quigley HA, et al. Doctor-patient communication in glaucoma care: analysis of videotaped encounters in community-based office practice. Ophthalmology. 2009;116(12):2277-2285.
- Hahn SR, Friedman DS, Quigley HA, et al. Effect of patient-centered communication training on discussion and detection of nonadherence in glaucoma. Ophthalmology. 2010;117(7):1339-1347.
- Broman AT, Quigley HA, West SK, et al. Estimating the rate of progressive visual field damage among those with open-angle glaucoma from cross-sectional data. Invest Ophthalmol Vis Sci. 2008;49(1):66-76.
- Friedman DS, Okeke CO, Jampel HD, et al. Risk factors for poor adherence to eyedrops in electronically monitored patients with glaucoma. Ophthalmology. 2009;116 (6):1097- 1105.
