The power of recommendation

There is significant healing power in the doctor-patient relationship. If we work together in these relationships, significant improvement can occur to our patient’s quality of life and health status.

The word “fudiciary” is derived from the Latin word for “trust.” This “trust” is the basis for the doctor-patient relationship. The bond between the doctor and patient is vital for a successful diagnostic and therapeutic outcome. The patient can trust that communication about her condition is held in confidence and that the doctor follows accepted codes of professional ethics.

The doctor-patient relationship has evolved over the centuries from paternalistic into a more shared decision-making model. This model allows for patients to be autonomous and express their views and choices, including no treatment. We must remember that our patients filter our instructions through their existing belief system before coming to a final action.

In the patient’s best interest

Remember that competent patients have a right to refuse care, and we must respect their decision. However, under vision- or life-threatening situations, we must strongly encourage specific actions, especially treatment that carries little risk. We can gently persuade the patient by educating him of the harm in avoiding or denying treatment.

Some experts suggest that patients should be the primary decision makers in their own health care and that doctors should not make treatment recommendations, including allowing patients to make their own choice¹ and that doctor’s recommendations can be influenced by industry.²

However, our recommendations have a strong influence on patient choice³ and are there to promote patients’ best interest.⁴ Cognitive patient biases affect the choices they make that are contradictive to their own best interest.^5,6 Our recommendations can potentially help our patients overcome these biases.

It has been shown that when people make decisions for others, they hone in on the most important aspect of the decision and are less swayed by other factors that could bias the decision.⁷ This confirms how important our recommendations are.

In the contact lens arena, we have a vast array of contact lens options and modalities to choose from, and the proper contact lens wear and care regimen ultimately depends on our patients following our instructions. Frank recommendations are often required so that our patients’ contact lens wear is safe, comfortable, and successful.

The power of a recommendation is often undervalued or overlooked.

How many times have you heard a patient say he is not complying with your written orders for contact lens wear and care, only to discover that the problem is you? I admittedly have. Knowing that one third to one half of patients fail to follow a doctor’s written orders ^8,9 makes the process of recommending vital to a patient’s health. Years ago, I found that bringing a personal touch to my patient relationships allows me to better connect to the patient and enhance my recommendations and my written orders.

I believe that compliance can be vastly improved by allowing patients to share in the decision making for their condition following my recommendations. For example, I might say, “I know that it may be hard to change your lenses at exactly every 2 weeks as I have prescribed. Let’s talk about what happens when you don’t change your lenses and come up with a solution together. I would suggest that you change them on the first and fifteenth of the month.”

While some may argue that patients can choose wisely,¹⁰ I cannot reiterate enough how important it is to make recommendations that ensure healthy contact lens care and wear and not leave it up to our patients to make their own decisions. Otherwise, why would they need us?

Obviously, there is a reason contact lenses are regulated as medical devices and their distribution restricted to licensed professionals, by the Food and Drug Administration. We know that civil penalties of up to $16,000 per violation can be assessed for the illegal sale of contact lenses. I am preaching to the choir when I say that contact lenses are a prescription device that if fit, worn, used, and taken care of incorrectly can lead to grave outcomes. The challenge is to convey this to our patients.

Building trust to increase compliance

Our patients can have safe and successful contact lens wear if we provide full-service care and they adhere to our prescribed orders. A few of those orders being:

• Lenses

• Care system

• Hygiene

• Wearing schedule

• Lubrication

• Environment

• Replacement schedule

• Comprehensive eye examination schedule

• Cases

• Follow-up

• Seek care when certain symptoms occur

Let me give you a common scenario that many of us face daily: you prescribe contact lenses, but fail to prescribe the care system, specific wearing schedule, specific replacement schedule and/or follow-up. Your patient ends up in the emergency department with a central corneal ulcer. That was your fault.¹¹

Our patients are best served when we are proactive with recommendations.

A successful recommendation begins with:

• Reducing barriers to communication

• Establishing a comfortable environment for doctor-patient interaction

• Small talk to connect on a personal level

• Focus on the patients’ needs

To facilitate open communication, some techniques are:

• Sit down

• Lean forward when listening

• Listen without interrupting

• Make eye contact

• Acknowledge feelings

• Explain, educate, and reassure

• Ask if you covered everything and if patients have any questions

• Be sincere

We have all seen the tragic events that occur when a patient does not follow our recommendations and ruins his vision for a lifetime.

It is of utmost importancethat we make proper recommendations for our contact lens patients so they comply with our written prescription orders.

You know what is best for your patient and you should make the call. Don’t let them make their own decisions about healthy contact lens wear; recommend.ODT

References

1. Veatch RM. Models for ethical medicine in a revolutionary age: what physician-patient roles foster the most ethical relationship? Hastings Cent Rep. 1972 Jun;2(3):5-7.+

2. Quill TE, Brody H. Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Ann Intern Med. 1996 Nov 1;125(9):763-769.

3. +Siminoff LA, Fetting JH. Effects of outcome framing on treatment decisions in the real world: impact of framing on adjuvant breast cancer decisions. Med Decis Making. 1989 Oct-Dec;9(4):262-71.
+4444. Ubel PA. “What should I do, doc?”: Some psychologic benefits of physician recommendations. Arch Intern Med. 2002 May 13;162(9):977-80.+

5. Redelmeier DA, Rozin P, Kahneman D. Understanding patients' decisions: cognitive and emotional perspectives. JAMA. 1993 Jul;270(1):72-6.+

6. Ubel PA. Is information always a good thing? Helping patients make “good” decisions. Med Care. 2002 Sep;40(9 Suppl):V39-44.+

7. Stone ER, Allgaier L. A social values analysis of self-other differences in decision making involving risk. Basic Appl Soc Psych. 2008;30(2):114-29.

8. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005 Aug 4;353(5):487-97. 16

9. Huang ES, Karter AJ, Danielson KK, Wartson EM, et al. The Association Between the Number Prescription Medications and Incident Falls in a Multi-ethnic Population of Adult Type-2 Diabetes Patients: The Diabetes and Aging Study. J Gen Intern Med. 2010 Feb;25(2):141-6.

10. Quill TE, Brody H. Finding a balance between recommendations and patient choice. Ann Intern Med. 1996 Nov;125(9):763-9.

11. Karpecki PM, Schechtman DL. Microbial threats in CL wear. Rev Optom. 2010 Dec;147(12):69-70.