A retinal specialist referred Mr. Gold, an 82-year-old widower who has age-related macular degeneration, for a low-vision evaluation. Mr. Gold has had AMD for several years, but he has noticed a significant decrease in vision in his better seeing eye in the past six months. Mr. Gold had to stop driving, and he no longer sees well enough to read his mail or write checks.
Mr. Gold now relies on his adult children for his meals, shopping and bill paying. He spends his days watching television, unable to participate in many of the activities that gave him personal independence and freedom. His children hope that a low-vision evaluation might help restore some of his independence.
This case has many elements that are common among patients who seek low-vision services. As an older person with age-related vision loss, Mr. Gold faces many new challenges in his life. As a low-vision specialist, what do you anticipate him to expect from a low-vision evaluation? What does he really hope to gain from your services? And, what gaps exist between his and your perceptions?
This article will explore the impact and importance of patient expectations from a low-vision evaluation, and will explore strategies and resources to meet these expectations.
Patients goals can be wide ranging, as the impact of a visual impairment is often pervasive and affects activities of daily living. In this instance, a closed circuit TV (CCTV) enlarges print, making magazines and newspapers easier to read.
The ability to understand patient expectations and fashion them into realistic goals is essential when providing vision rehabilitation services. Within the past 15 years, medical and rehabilitation professionals have been paying greater attention to what patients want and expect. And, patients increasingly want to assume a more active role in their health care.1
Patient expectations are one of the primary determinants of patient satisfaction.2,3 Patients come to doctors looking for assistance that may include a wide range of servicesfrom psychological support to specific medical tests, treatment and rehabilitation.4
Favorable clinical outcomes, though, can only be achieved when both the patient and doctor have similar expectations. Studies have demonstrated that doctors need to work with patients to clarify and assist in developing appropriate expectations.5
This is particularly relevant for low-vision rehabilitation services. Patient expectations for low-vision services may range from wanting vision restored or obtaining conventional glasses to correct the problem, to very concrete activities that can be achieved with low-vision intervention. Patients goals can be wide ranging, as the impact of a visual impairment is often pervasive and affects activities of daily living, mobility, school and leisure.
Besides the changes in daily functioning, most individuals experience an emotional adjustment process as they come to terms with their vision loss. The psychosocial impact of visual impairment varies in intensity and duration for each individual. So, potential goals and expectations from a low-vision evaluation will be highly individualized.
Expectations for low-vision services are also shaped by other factors. These may include the degree to which patients and physicians understand the visual impairment, the level of knowledge about the low-vision evaluation, and the patients conceptions of the capabilities of low-vision devices.6 The degree to which you can convert expectations into realistic, achievable goals is important for you to address with the patient.
Information from a variety of sources, including other individuals with low vision and eye care or medical practitioners, may shape patients expectations for the evaluation. Youll also need to consider what the patient thinks he or she can achieve with low-vision services. A patient who hopes to cure visual impairment or who expects conventional spectacle correction to resolve all visual difficulties may not completely understand low-vision services. Or, perhaps that patient has not fully accepted that his or her vision loss is permanent.
Assess Patient Goals
You can assess patient goals by having patients complete a questionnaire before the examination (see Pre-Evaluation Questionnaire, below). You should review the patients responses before the appointment.
|1. What is your understanding of your vision problem?|
2. Can you see print the size of a newspaper headline?
3. At what distance can you see the television most clearly?
4. Have you tried using magnifiers in the past and, if so, have
you found these helpful?
5. Do you have any difficulty walking around indoors or
outdoors because of your vision?
6. What activities would you like to do better as a result of the
When patients schedule appointments, they should receive an explanation of what the low-vision evaluation can offer. Your office staff can do this verbally or can mail this information to the patient. If you choose the latter option, remember that patients may be unable to read standard print, so patient materials should be provided in large print, on glare-free paper or in an auditory format (cassette tape or compact disc).
Patient education is essential for helping patients formulate achievable goals. A questionnaire will also encourage patients to begin thinking about their lives, how the vision problem has affected them and what they hope to accomplish as a result of the low-vision evaluation.
There are three steps you and your patients can take to facilitate this process. First, encourage them to think about the range of activities that have been affected by vision (see Preparing for the Low-Vision Examination, below).
Preparing for the Low-Vision Examination
|Patients should bring the following to the low-vision exam:|
A list of daily activities they cannot do as well or easily as
they would like due to poor vision. These should be
activities the patient would like to resume, if possible.
Any glasses they have, even if those glasses do not help.
Any magnifiers or other low-vision devices they currently use.
A list of any medications they are taking. Patients should
also ask their primary eye care specialist to send information
from the most recent examination.
Second, realize that low-vision services and devices alone may not fully address some of the activities on the list. For this reason, you should be familiar with the broader range of services available in the community. These may include: vocational rehabilitation services, community integration activities, and orientation and mobility instruction. Vocational rehabilitation counseling and educational support may often offer further options to meeting patient goals.
Third, look into additional services, such as support groups and various other organizations (see Resources for Low-Vision Patients and Families, below). An important resource: local and state agencies for the visually impaired, which are listed in the blue pages of the phone book and on the Internet. You can facilitate the referral process by keeping brochures about these agencies in your office.
|Resources for Low-Vision Patients and Families|
| State agency for the visually impaired. Services include |
rehabilitation teaching, orientation and mobility instruction,
and vocational rehabilitation counseling.
Area agency on aging. Services include case management,
support for caregivers and in-home support.
Support groups and consumer organizations. Examples
include the Association for Macular Diseases
Foundation Fighting Blindness (www.blindness.org).
Always begin the low-vision evaluation with a thorough patient history. Listen carefully to the patients goals or concerns so that the evaluation moves in a meaningful direction for the patient.
The patient history should explore various aspects of function, including reading, activities of daily living, mobility and leisure activities. Discuss employment and school if either are relevant to the patients life situation.
However, do not to assume that every problem the patient experiences is automatically a goal for the low-vision evaluation. Some individuals may willingly relinquish certain responsibilities, such as shopping and bill paying, to others.
Realize that family members may have different goals and expectations. Take Mr. Gold, for example. He may prefer that his children perform many of the activities that have become difficult for him and may be content to watch television for most of the day. His children, however, may feel that this is unacceptable. You may need to refer families to other services, such as area agencies on aging or support groups, to address their needs.
Communication is Key
Patient goals and expectations may shift or expand as the low-vision evaluation progresses, especially once the patient works with devices and has a better understanding of what magnification can and cannot do. A seemingly impossible task may become achievable once the patient learns how to use remaining vision more efficiently and low-vision devices appropriately. Conversely, some individuals may decide that performing certain activities using vision may not be the most efficient for them. An ongoing dialog between you and the patient is necessary for meeting the patients expectations.
Effective communication is a key aspect of the low-vision evaluation and will promote a greater potential for successful outcomes. An O.D. who conveys a sense of warmth and genuine caring establishes a trusting doctor-patient relationship.
To build this rapport, listen for and acknowledge the patients feelings. In many cases, you, the low-vision practitioner, may be the first doctor to really focus on the problem areas experienced by the patient. So, you may be the first person with whom patients share strong feelingssuch as fear, anger, sadness, frustration and depressionthat result from vision loss.
Most importantly, allow the patient time to talk. This lets you establish a trusting relationship and ultimately provide more effective services to the patient. If emotional issues have a profound impact on the persons ability to function, you may need to refer him or her for psychosocial intervention.
Low-vision care requires attention to the whole person, not just the physical aspect of vision loss. Education and information are essential for cultivating realistic expectations and achievable goals.
The extra time and effort to elicit this information prior to the evaluation and throughout the low-vision process is a valuable investment to achieve more meaningful outcomes. Also, effective communication between the patient and practitioner is paramount in the success of each and every case.
Dr. Brilliant is an associate professor at Pennsylvania College of Optometry in Elkins Park, Pa. He is senior low-vision practitioner and is professor in charge of and lecturer of low-vision rehabilitation. Ms. Graboyes is coordinator of social services at the William Feinbloom Vision Rehabilitation Center at PCO and an associate professor in the Department of Graduate Studies.
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2. Linder-Pelz SU. Toward a theory of patient satisfaction. Soc Sci Med 1982;16(5):577-82.
3. Ford RC, Bach SA, Fottler MD. Methods of measuring patient satisfaction in health care organizations. Health Care Manage Rev 1997 Spring;22(2):74-89.
4. Peck BM, Asch DA, Goold SD, et al. Measuring patient expectations: does the instrument affect satisfaction or expectations? Med Care 2001 Jan;39(1):100-8.
5. Mondloch MV, Cole DC, Frank JW. Does how you do depend on how you think youll do? A systematic review of the evidence for a relation between patients recovery expectations and health outcomes. CMAJ 2001 Jul 24;165(2):174-9.
6. Siemsen DW, Bergstrom AR, Hathaway JC. Efficacy of a low vision patient consultation. JVIB 2005 July,99(7):426-30.