This week I had three very interesting patients.  The thing that made them particularly interesting was the challenge I faced when communicating with them.  One was a patient with a myriad of health issues who spoke no English and required a translator, another was aphasic after suffering a stroke in February and the third was extremely worried about glaucoma.

I have worked with patients who do not speak English before (with varying success, I must admit).  In fact, the second eye test I did as a pre-reg was a Polish lady who came in for her first eye test, worried about her failing vision (it was presbyopia, much to her – and my – relief).

If you are wondering, my first eye test was a 74 year old diabetic who sat and looked at his watch for the entire time he was in my room, only to declare (halfway through my test) that he needed to be somewhere NOW and that he didn’t realise he’d been booked in with the “student optician”.  He left and later called to arrange a second appointment, I was unfortunate to pick up the phone and get told that he was in that morning, the student optician took far too long, he’s a busy man and he didn’t want to see her again.  I didn’t have the heart to say, “It’s me, the student optician, and you were my first ever real patient outside of uni.”  To say I was disheartened was an understatement.  Since then, I’ve felt guilty about how long it takes for me to test.  Now I’m testing at around 30mins, like a “real optom” for most patients, but for the first few months, I was painfully aware of how slow I was.

Anyway, the first patient I want to talk about was a middle-aged man who spoke very little English (C).  He was diabetic and had several other health issues.  His son had come in with his dad and was acting as translator.  The son (D) knew one of our optical consultants (and they spoke the same language) so I asked that OC to pre-screen my patient, since I thought it would put him at ease and speed up the process.

The eye test was quite straightforward.  When speaking with someone through a translator, we are told to ignore the translator and speak directly to our patient.  This works if it’s a professional translator but not so much if the person is a worried relative.  History and symptoms was simple and C was one of those wonderful patients who carries their list of medicines with them.  During the rest of the test, I tried to explain what I was going to do in advance (and then wait a second or two for this to be passed on) rather than at the same time as I was going it.  These little changes in the way I communicate during my routine have become second nature.  

At the end of the test, there was no sign of diabetic retinopathy but there had been a large (+1.50DS) hyperopic shift in C’s left eye since his previous test (at another optician).  He was on both metformin and insulin and self-monitored his blood sugar.  I asked when he was last seen at his GP or at the hospital for his blood sugar.  It’d been a long time and he said he couldn’t get it under control.  He knew the ideal level was 6 to 8 and he regularly tested as 18 and above.  I’ve written to his GP about the blood sugar and I advised him not to get new specs until he gets it under better control.

The lady who was aphasic was 50 and had suffered a stroke in February.  She had good motor control but was struggling to communicate.  As she had been tested at our store before, I was in a good position.  I looked through the previous card and tried to do as much of my history and symptoms as closed questions. “Do you wear glasses at the moment? For distance? For reading? Is your vision good with your current glasses? Could it be better?” Although that looks like one giant, compound question, I made sure that I gave my patient enough time to answer, and elaborate, if she wanted.

At certain points, I could see my patient becoming frustrated but she managed to make herself understood.  I had to fight the urge to finish her sentences.  During refraction, I tried to keep all my questions to yes or no, 1 or 2.  After the test, I dispensed my patient as well – I thought she would be more comfortable continuing to deal with me.  If you are able, it’s great to be able to give patients with communication difficulties this level of continuity (prescreen to test to dispense).

One of the most difficult communication situations this week was a man who was very concerned about glaucoma.  This gentleman had been booked in as the last test on a Sunday.  He arrived 10 minutes late and was booked in as a standard eye test but he was over 60.  From the start, I felt under a bit of pressure as I didn’t have a lot of time.  I did the prescreen and, at that point, I realised that he was very worried about his eye health.  When I tested his visual fields, he would ask if he was giving the correct answer over and over again.  At the end of the test, he wanted to know if it was normal (it was).  The same happened after NCT and after I took a fundus photo.

I showed the gent into my room and had a good look at the photo I had just taken (in the prescreen area).  He had advanced dry AMD in both eyes.  My heart sank a little.

During history and symptoms, I learned that his mum was almost blind from glaucoma.  She had some useful vision left in one eye but the vision in her other eye was now “completely gone”.  

Now, when I’m going through my routine, I will constantly say “good”, “great” or “perfect” when I’m finishing one test and moving onto the next.  It’s a little verbal tic that I have and some patients really like it (I’ve had patients tell me that I made them feel very positive during the test).  This patient started analysing what I was saying.  “You said ‘good’ there but you said ‘perfect’ before – does that mean that something is wrong?”

I was a bit nonplussed by this.  

I told him that I used “good”, “great” and “perfect” interchangeably and if anything was wrong, I would tell him.  He seemed quite happy about that.  

When I refracted him, he was 6/4.5 in each eye and there was only a small change in his Rx from last year.  I asked him about the macular degeneration (he didn’t mention this at any point so I was worried that he didn’t know) and he said, “Oh, yes, I’ve had that for years.”  I found it strange that he was more focused on developing glaucoma and going blind than losing his sight from AMD.  I gave him an Amsler chart to take home and advised him on vitamins and diet.  When he left, I was still a bit puzzled by the fact he was so concerned about one eye disease but he completely ignored the pathology he already had.  I guess that, having seen his mum’s vision slowly be stolen from her, he feels that glaucoma is more “real” to him than AMD.

Oh well.  People are strange.

I’ve posted my OSCE application and, fingers crossed, I may have a place on the J&J Vision Care Institute OSCE course in June (Friday, 6th June, if anyone else is going).