Lecture: Patient Communication in Ophthalmic Practice – Challenges in the time of COVID-19

Hello, everyone. I am Neha from Orbis India and hope you all are doing great and keeping safe in this lockdown period. Everyone welcome to yet another webinar in the series of unlocking possibilities during the new normal. Today’s webinar is in Patient Communication in Ophthalmic Practice – Challenges in the Time of COVID-19. And it is my great honor to introduce Kenneth Youngstein to all of you. Ken did his graduate studies in psychology and neuroscience, but in the mid-1970’s he found his true passion in health communication. How industry talks to doctors and how doctors talk to patients. In these 45 years he’s worked all over the world. And Ken has been volunteering his services to Orbis since 2012, working with us in Africa, Asia and Latin American. And has developed educational tools for professionals, patients, and public. Thank you so much, Ken, for joining us today. And we really look forward to your talk today.
[Kenneth] Thank you, Neha! And I would also like to welcome everyone to this webinar on challenges in the time on COVID, this unlocking possibilities. And if you haven’t already seen the other presentations in this series, I highly recommend that you go take the time to look at these, because they really are very, very interesting.
As we are now required, I’m going to now show you a disclaimer. That basically says is that information is changing very rapidly, so anything I say today may not be applicable tomorrow. So please refer to your local country, local authorities for the latest applicable data, policies, and guidance. So with that bit of housekeeping out of the way…
As Neha mentioned, I’ve already been working with Orbis for 8 years. And some of you may already be familiar with one of the projects I’ve developed, which is called The Singing Tree. It’s the story of a young girl with refractive ERA, she sits under the tree and thinks that the tree sings to her because she can’t see the birds. And so that’s why it’s called The Singing Tree. And it is now been done in 10 countries, 22 languages. The newest country we’re going to launch, very soon too, will be in Ghana, this one here. And also in Mongolia. If you’re living in a country that doesn’t have this already and you’re interested, please contact Orbis, and we can explore whether or not you would like to have The Singing Tree in your country as well.
So when we introduced The Singing Tree in India, in 2018, it was included on the list of the most important books released that year. We had the number two position. So I’m very proud of that case. We now need to go back nearly 20 years before this to 1999. And in 1999, as you know, the World Health Organization and all the members of the International Agency for the Prevention of Blindness, launched an initiative called Vision 2020. Well, here we are in 2020 and instead of celebrating all the wonderful things that have been done in this time, we find ourselves in a lockdown, due to the coronavirus, the COVID-19.
This virus, this pandemic, has really impacted our lives tremendously and not just as healthcare, but businesses, people, everybody’s been affected by this. And I’d like to, just very briefly, talk about how the COVID-19 pandemic has impacted healthcare systems and specifically in ophthalmology.
First, there are direct impacts. And the direct impacts, well, we now have 14.5 million people with the disease, with over 600,000 deaths. And many of these people who have fallen victim to this disease, both in terms of morbidity and mortality, have been healthcare professionals, people on the front lines. So it’s really affected the healthcare industry quite directly. And it’s put really a big strain on the healthcare system in general.
And then there are indirect impacts. And these indirect impacts really affect, you’ll see how they affect our delivery of healthcare. First of all, is the restriction of movement of people. People aren’t able to move within their communities or outside to a neighboring community, or anywhere in the country or abroad, which really restricts their access to healthcare. Many people have a fear of going to hospital, the idea that, gee, if I go to the hospital, maybe I will get sick? And this has meant, and also because of the lockdown, people do not have, they may have lost income, so they have financial problems. And this is also true for the hospitals, because the hospitals have directed so much of their resources to treating COVID, that many hospitals around the world are facing tremendous financial problems.
How has this impacted directly on patients? Well, many patients have had to delay seeking care. Which means they’re coming to you at a much later stage in their disease that might have been normally. They have, as I mentioned, greater financial problems, which means their options, with regards to care, or even transportation. Having money to take a bus or a taxi to come visit you may be restricted. This has all put patients under much greater personal stress than we normally see. And so we have to take this into consideration in every way in which we deal with patients. An important part is this, is that as you know and we’ll talk about later, many of your patients don’t come alone to the clinic. They normally come with somebody else from the family. Under these restrictions, right now of travel, they may have to come alone. And this also changes the dynamic tremendously. And we shouldn’t forget that patients may have, or often do have, other illnesses and one of these could even be COVID-19 infection.
Unfortunately, we are also facing a second pandemic. And this one is almost as dangerous as the first. And this is a pandemic of misinformation. And we, this information could either be intentional, which is what we call disinformation, or it’s just ridiculous information bordering on conspiracy theories or things that are just simply not true.
So, how does it impact the way in which we practice? Well, first of all, it can increase the risk of individuals. There are a lot of things floating around the universe of the internet, things like, COVID-19 is no more dangerous than the flu, or wearing a mask or social distancing doesn’t really lower your risk. Or if you’re under 65, you’re not at risk. How about children cannot get sick. And finally, there’s COVID-19 vaccination is part of a global conspiracy. I mean, these I find quite astounding, especially since they involve very often people like Bill Gates and the pharma companies, that they’re trying to use the COVID vaccine. So this, of course, will influence us tremendously as healthcare providers, if we do develop a vaccine and people don’t want to use it.
Why is this so important? What is the real impact of misinformation? And the biggest effect is that it decreases trust. And trust is really the foundation for all of our healthcare system. So basically, when you erode trust, you erode the real foundations of everything that we base for our system. So what is our strongest treatment for misinformation? And that is communication.
What is communication? Well, this is my favorite definition. Communication is a process in which a person, through the use of signs or symbols, verbally and non-verbally, but intentionally conveys meaning to another in order to affect change. The keywords here are “to affect change.” If you don’t affect change, you’re basically just moving information or data from point A to point B. So our goal is really to affect change through communication.
Communication is a bit of a pyramid. You have to really start at the top. Many countries around the world are already dealing with this problem of misinformation and I think it’s important for you, on a local level, to look at what your countries are doing and follow their guidelines as close as possible so that all communication to the patients, to your staff, are consistent with the national policy.
Then, there’s your community. So work with your local governments, health departments, people in your area to make sure that you are always delivering the most active information. Really, your role as healthcare professionals to give this information to the people who run your communities.
Then there’s your institution. It’s really important that within your own institutions, you have to remember that your employees are also subjects to this misinformation. They may have a certain degree of resistance because they’re healthcare professionals, but they’re certainly not immune. So it’s very important that in the next couple of weeks, you try and get your staff together. Have them talk openly about what are they hearing, what do they believe about COVID, about this current situation? And so that you can identify what are the misconceptions within your own professionals and what you need to do to correct that.
And when I talk about your institution, I’m talking not just about the doctors and the nurses, but anybody who comes in contact with your patient groups. It’s important that you understand what their understanding of the situation is and what you need to do to be able to correct that. And then finally at the bottom, there is your patients. What are they hearing, what do they know, what are their beliefs?
Patient communication has several benefits. And these are the three most obvious ones. By good communication you will end up with a better diagnosis, you’ll also end up with better treatment options, and you’ll also reduce patient loss from care. And what do I mean by that? Well, you all understand this. I’d like to make a comment. You may notice that the slides in my presentation have a very Indian theme. That’s because for the next eight weeks, I will be doing eight webinars. And this is the last one I was asked to do, so I was borrowing images from all the other presentations I’m doing. And that is why these slides have so many Indian references.
So, patient loss, you’ve all experienced this. You do a screening, a camp somewhere, you identify a large group of people and then you tell them, “Okay, come to the clinic.” Well, not everybody shows up at the clinic. And then those who do show up to the clinic, there’s also a loss at the next level coming to treatment, and then you do the treatment and then you’ve lost more people following up. One of the best ways to limit, to reduce patient loss, is through good communication.
Let’s get back to our list here. I said reduce patient loss from care, better treatment adherence, this is a problem that all of you know. You prescribe medications to patients, the chances of them taking it are often very low. The best way to improve adherence is through communication. This will lead to better patient outcomes, which is something we all want. What’s also important is it will increase the satisfaction of your patients with their care. And this is important. After they’ve been to see you, they’ve been treated, they go back to their homes, to their villages, their towns and they say, “Gee, I just had the greatest experience at this certain clinic.” So good patient outcomes really increases the spread of your services.
Internally, we have found over the years that when these things happen, job satisfaction is also increased. You also get an increase in productivity, and for those of you who are administrators, there’s also better business for the clinic. So it seems to be a win for everyone.
In this program, I’m going to talk a lot about communication with patients and families. And the reason I always start with families, we talk about families, is because as I mentioned earlier, patients, especially in part of the country outside the United States or Europe, patients rarely come alone. If it’s a child, the patient will always come with a parent, a mother, or a father, or a grandmother, an auntie, somebody. And in the case of older patients, they most always come with an adult daughter or an adult son. And I found it interesting, culturally. When sons and daughters will come, if people feel safe to travel, that’s the daughter. And in places where they don’t feel safe to travel, then the son is often the person who brings the adult, the elderly patient. But that’s a topic for another discussion.
Let’s talk about the doctor-patient relationship. The doctor-patient relationship is based really upon the patient and the family having trust in the doctor. They trust you, basically, to identify their problems, come up with the best solutions and to work together. But how do you get this trust? Well, the way in which you get this trust is the way in which you show respect for the patient. So quite simply, you do this through communication. It is also the quickest way to lose their trust is by bad communication. And if you speak to anybody, patients, they will tell you this. If the doctor showed their respect, they will trust them, if they don’t they will not. Using good communication skills is your most effective way to gain this respect.
Now traditionally, the doctor-patient relationship looked something like this. The doctor had all the power, he has all the knowledge, and subsequently, in a doctor-patient discussion, in a meeting, the doctor did almost all the talking and the patient sat there and listened to the doctor as he or she talked. Well, things have changed and today we have much more of an egalitarian point of view. And we view medicine really as a partnership between doctors and patients, where there’s a sharing of information, a sharing of decision making regarding treatment as well.
So consequently it isn’t the doctor who does all the talking, but there’s a discussion. A two way flow of information. And in general, if you find that you are doing all the talking, and the patient is doing most of the listening, your communication is wrong. So try and create, in every situation, a dialogue where there is a sharing.
Unfortunately, there is no simple script that you can follow that’s right for all patients. Each patient is unique, with his own needs, his own circumstances and therefore, communication has to be tailored to each patient. And what this is called is patient centric communication.
In English we have two words: disease and an illness. Now, I’ve discovered since I speak in quite a few languages. Oh, by the way, I never mentioned this. I live in Switzerland. And I’m talking to you from my office in Zurich. In English there are two words, there is disease and there is illness. Disease is how the doctor sees the problem, it’s the pathologies, the symptoms. But the patient experiences the illness. And this is the symptoms, but not the same as a clouding of the lens. For the patient it is a gradual loss of vision. And how does it affect his or her life? “Well, I can’t see as well, I can’t drive my car anymore,” or, “I’m having problems at work, to do my work, because I don’t see as well.” And this leads to fear and anxiety. “Oh my God, I may lose my job,” or, “I may actually go blind.” So we have to understand that the goal of healthcare is not just to treat disease, but also to treat illness as well.
In general, it’s common to talk about any discussion with a patient, which we’ll call a consultation, in five steps. You initiate the consultation, then you gather information, you do a physical examination, then there’s the explanation of what the problem is, planning, and then finally the closing. When I do my workshops, either live or on the internet, I cover all five of these. But for today’s discussion I’m really going to focus on the first one, this initiating the consultation. Because within this phase, I think this is where most people make their mistakes, where they really blow it. (laughs) Where they lose the trust, where they either gain or they lose the trust. So I’d like to focus on this. Because also some of the techniques I will talk about are very helpful in general. Not just in a consultation but talking to your colleagues, talking to your wife, talking to your children, talking to your friends. Using these ideas, I think, will also help you in all of these respects.
To do this, I would like to take a very typical scene. Now I have worked in eye clinics all over the world. Africa, India, Myanmar, Nepal, you name it. In many different places, China. And this is sort of a typical scene. First of all, there are many patients in the waiting room. I think some of them have traveled all night, come early in the morning. The basic tests are done by a nurse or a technician. The nurse brings a pile of patient charts into the doctor’s office, puts them on the doctor’s desk, and then the next patient enters the room, and sits down.
The doctor picks up the chart on the top of the pile, he looks at the chart, makes an evaluation, maybe does some additional tests. Then the doctor starts to speak to the patient. He explains the diagnosis, prescribes a treatment, and finally the doctor asks, “Do you have any questions?” Well, the patient typically says, “No,” or just shakes her head. She leaves and the next patient comes in. So I’m sure you are familiar with this scenario.
Let’s look at an alternative. This time let’s do things a little differently. This time, the doctor reads the patient’s chart before the patient comes into the room. Then the patient enters, he greets her with a smile, and he asks her name. He introduces himself and clarifies his role. He maintains eye contact with the patient as he speaks. He invites the patient to sit down and asks if she is comfortable. He asks the patient why she has come to the clinic. He listens to her as she speaks, he encourages her to provide more details. Each time he performs a test, he first explains why he is doing the test and asks the patient’s permission to proceed.
Why is this? What’s changed? First of all, you’re prepared before the patient enters the room. So that you can focus all your attention on the patient and not on the chart. By asking the patient her name, you’re certain you have the correct patient. I’ve been in clinics where this is not always the case! Where the patient and the chart are not the same person.
But equally important, it establishes that you understand what you have said. And that you speak the same language. So just by asking her name and her response, you can tell whether or not you can communicate effectively with this. Over the years this language issue is quite important, because I’ve been in many clinics where the doctors come from different regions than the patients they see and may not be very good with the local language. Or people travel from great distances and they may not be able to speak the language of the clinic where they are. So just by asking this question, you first establish if they understand.
Introducing yourself, this is really important. A patient needs to know who you are and what you do, what is your role here. And by doing this, by asking the patient to please sit down and to be comfortable, you demonstrated interest and respect for the patient and her comfort. I was at a clinic in West Africa and it was a retina clinic. And retinal patients are very often diabetics. Diabetics very often have a problem with their feet. So in came an older man, on crutches, with toes that had been amputated, you could see. And the only seat he has to sit down is a very, very small stool in front of the doctor. And as he tries to sit down, he literally falls off and a nurse has to catch him before he hits the floor. This is not a very good way to start a relationship, to start an interaction with your patients. So asking the patient to sit down and to ask if she’s comfortable is important.
This next thing about, he asked the patient why she has come to the clinic. You didn’t didn’t tell her why, because very often on the form, the chart you already got from the nurse, it may say cataract or glaucoma or increased pressure. The important thing is to ask her to tell you why she has come and I’m going to return to this point very soon. And then finally, by telling her why you want to perform a test and asking her permission, you have made her a partner.
You want to look inside the eye? You say, “Oh, I would now like to look inside your eye, if you will just rest your chin here on this piece, I’m going to shine a light into your eye. This is not painful. And this way I could look at the back of your eye. Is that okay with you?” This changes this whole opening reaction extremely. I’d also like to notice that nothing so far has increased the amount of time you need with this patient.
I’d like to go back to this part about he asked the patient why she has come to the clinic. This is very important. Because also, and it’s not as easy as you think. You should not always reply upon the information on the chart to know why a patient has come. And this is called the opening question. Let’s look at the opening question.
The wrong way to do it are things like, “How are you today?” Well, it’s a nice question but it’s too broad, it doesn’t focus on the problem. “Yeah, I’m tired, I just had a long bus ride.” Whatever it is. Then if you ask, “What can I do for you?” That focuses on you and not for the patient. And if you ask a patient a question like, “When did your symptoms begin?” Well, the patient might say, “Yesterday,” or, “Two days ago,” or, “A month ago.” And what have you really learned? Instead, how about asking a question like, “Please tell me why you have come to the clinic today?” Or, “Tell me about when your symptoms began?”
These are examples of what is called an open question. And an open question is a question that cannot simply be answered with a yes or a no, or in one or two words. These questions like, “When did your symptoms begin?” That’s a perfect example of a closed question. So it is very important in your opening question, when you start your discussion with the patient, to always start with an open question. And the easiest one is basically, “Tell me why you’ve come to the clinic today?”
Throughout your discussion it’s good to use a mix of open questions and closed questions. Start with an open question, tell me about, and the more they tell you then you can use closed questions to focus on the details. Things like okay, you told me about when this started, when did it start, how long has this been going on, do you have this symptom, or do you have that symptom? So we use what is called the open-to-closed cone. Start with open questions and then come down to more focused questions.
Now, the opening question can give you several important clues, and important information. I mentioned before that it can tell you about the person’s language. Also, listening to the opening question tells you a bit about their education, it tells you about their concerns, and most of all, it tells you about their disease beliefs. Now this is something that is essential.
I’m going to assume that the people listening to this lecture have what we call a science-based disease model. We believe in bacteria and viruses, we believe in the efficacy of antibiotics and antivirals. And we understand inflammation, the role of anti-inflammatory medications. But not everybody has the same view of the world. There are many people who have, what you might call, a religious-based disease belief. That basically disease is punishment from God and the best way to treat this thing therefore is to pray. There could also be shamanistic points of view, it’s an imbalance in the natural world and therefore it’s cured only by traditional medications.
I worked for many years as the head of the Liberian Institute for Tropical Medicine, in Liberia. And we also ran a small clinic on the side. And I will tell you, in West Africa, nearly every single illness is caused by a curse by somebody who doesn’t like you, juju. “This woman thinks I tried to steal her husband and that’s why I’m feeling sick today.” So these kinds of nonscientific-based disease beliefs are extremely common throughout the world, not just in what we might call the developing world. I’ll tell you, in Switzerland or in the United States, people also have very, very interesting beliefs about the nature of illness and therefore the nature of cures. So understanding a patient’s disease beliefs is essential. Unless you understand what their beliefs are, you cannot have a discussion with them about what is the disease and what are the treatments.
My advice to you is that no matter how bizarre and how silly it is, you must always show respect for a patient’s disease beliefs. So you can’t say, “Uh, that is nonsense! How could you believe is something so stupid as that?” Or, “Gee, there is really nothing to worry about. Why should you be concerned?” Always try to show respect because the moment you show disrespect for their beliefs, you have shut off any possibly for communication with this patient. I know it’s not easy, but you really have to learn to do this.
And the most important thing, when you ask the opening question, is that you have to listen. Listening is the key to good communication. It is said that there are two types of people in this world. There are those who listen and those who wait to talk. Now, you have to decide which one are you. Do you listen or do you wait to talk? I think we all know of many people who fall into this second category. And I think the more we have experienced, the more knowledge that we have, we just want to give this knowledge all the time.
I would tell you, this form of a webinar I find most disturbing for myself because in this situation I’m violating all of the rules (laughs) that I have been telling you about. I’m doing all the talking and I’m basically am not listening to anybody, and so I find this extremely disturbing way to do communication. But this is where we are. So I hope you understand the difference between these two types and think about who are you? Do you listen or do you wait to talk? And are you willing to change?
When we do listening, listening today is called attentive listening. Or engaged listening, there’s all different words for it. But this is something you have to practice. And the first part of this is learning to wait. In studies, consistently, we find that doctors in a consultation, after eight seconds will interrupt their patients. Okay, so that goes down to the second one. Don’t interrupt, wait.
The other thing is to facilitate responses, encourage the patient to continue speaking. “Oh, I see, so you’ve had this problem for two weeks. Tell me about this problem.” Or, “Tell me a bit more about it.” Or, “You seem to get quite concerned about this, tell me about that.” So really encourage the patient to expand on the things that they’re talking about and do not interrupt.
Think about non-verbal communication. Both on your side and the patient side. Lean in, show the patient that you are interested in what they are saying. Don’t keep looking at notes or at your computer screen, look at the patient, show them that you are engaged and that you are listening. And while you are listening, also listen with your eyes. Look at the patient’s body language. Are they in pain, are they comfortable, are they distressed? And use this information that you’ve been able to gain.
At the end of listening, the important thing is that you always have to confirm what you have heard. So what you do, basically, is give the patient a summary of what you’ve heard. “If I understood you correctly, you have had these headaches for the past month, and soon after you noticed that your vision is not as good as it used to be. And it seems to be more in the evening then it is during the day, et cetera.” So you do this. And then at the end, you say to the patient, “Is that correct?” And also, “Is there anything you would want to add to that?”
This leads us to the Mantra of Communication. And that is ask questions, listen, and then confirm. Sorry, just a second here, I got ahead of myself here. That’s our mantra, please remember that. If you remember anything at all that I’ve talked about today, this is the most important.
Normally, as I said, in a workshop I would look at all five stages of the consultation. I’m just going to look at the initiating the consultation and some of the skills that are involved here. If you want to see the full five stages, you have to attend one of my other webinars on communicating with patients.
It is clear that learning communication skills is not easy. And it’s not something that’s going to happen very quickly. Some people think, oh, you have to be born a good communicator. It’s not something you can learn. That’s nonsense. Anybody can learn to be a good communicator. But in order to do this, you have to have a commitment on the part of the people in your practice to learn the concepts and to practice them. And that this is something that has to be throughout the entire organization, to make communication a priority.
So the question is, how can Orbis help? How can we help you to become better communicators? And what Orbis is doing is basically to create communication tools, to conduct live workshops. If not for the pandemic, I was scheduled just in these past few months to be twice in India, two weeks each, so a month in India. To be several weeks in Ghana, Mongolia, and Lima, Peru. (laughs) So we are doing live workshops as soon as the world gets back to normal. We are also conducting online courses. There’s also an online interactive simulation software, which I have developed and used for the past 30 years, which we will be offering to the communities. And we are also going to work with our partners in each of the countries, to create regional centers of excellence in communication. So we will train trainors, who can then work with local hospitals and eye clinics, to do these kinds of things.
One of the first things I’d like to talk about is this idea of communication tools. And this is something called The Eye Book. Now, The Eye Book, if you can see your monitors additionally, comes in different sizes and formats. Here’s a spiral, this is a ring binder. So we have these available. And we have already developed The Eye Book in several countries. There’s some in Africa, in South Africa, and Zambia, and English, Ethiopia. Cameroon, in Ghana, India, now in eight languages. And Myanmar in two languages, Nepal in two languages and for Peru and Bolivia in Spanish. So this is something that we can adapt, not only by the language, but we change all of the content in the book to reflect the local culture, the local practice, and even all of the illustrations are done with local faces. So we have African faces in Africa, Indian faces, Latin American faces, Southeast Asian, whatever is appropriate.
Let’s look at what The Eye Book does. It begins with a section on normal anatomy of the eye. And as I said, all of these illustrations, the illustrations of the faces are all localized and they will be in local language. We then describe all of the major diseases that you would have, the book is divided into two separate sections. One for adult and one for pediatric, I’ll talk about that in a moment.
And let’s look at, for example, at cataract. Each disease starts with a text page. This is the most important key messages that you want to make sure you deliver when you speak to a patient. It’s basically the problem, why is it important to treat it, and then what are the treatment options? This is not meant to be read. I want to go back, I’m sorry, I forgot to mention something very important. The Eye Book is never to be given to the patient or to the family. The Eye Book is strictly a tool to be used by healthcare professionals when they discuss these things with the patients. So the doctor, or the nurse, the technician, is the person in control, is holding the book at all times and using it.
These key messages, if you want to read them, fine. Otherwise, learn them, read them, put them into your own way, but make sure that you cover all of these important information. By also using this book throughout your clinic, you are ensuring that you will have consistent messaging, no matter who is talking to the patient. This should not be left up to individuals to decide what they think is important and what is not important. This is what you decide is important.
Okay, so after the key messages, then we show a picture, it’s either an illustration, sometimes it’s a photograph, of what is the problem. And then we have this page. And I think this is very important, because this page shows the illness from the point of view of the patient. So the first panel is what is normal, then an early cataract, advanced and extreme cataract.
Now this is important, not just in your communication with the patient, but also with the patient’s family member. So assume you have an older patient who comes with an adult son or daughter. You can say, look, this is where your father is right now. Here, or maybe there, or let’s start here. In a few months it will be like this and if it’s not treated, it will be like this. Are you prepared to have a blind father? And the impact it will have on you? Will you be able to continue working full-time, what will be the impact? And I think if you do this, if you show this from the point of view of the patient’s experience, that the family members will understand, ah, this is something that has to be treated now, immediately, or as quickly as possible.
Let’s see here. Let’s go on to the next one. So this is followed then. I want to show you, this is what we’ve done for other diseases as well. So here’s glaucoma, again it shows the progression of the disease, or diabetic retinopathy. In addition, we show, if you need it, the actual anatomy. This is the normal anatomy, what light should look like, happen in the eye. And this is what happens with a cataract, this is why you have the blurred vision.
In the case of cataract, and some others we actually show what the surgical procedure looks like. We’ve made it extremely simple here so that anybody could understand it. This also avoids a lot of misconceptions that people have about surgery. In Africa, for example, in South Africa, people always think, oh, you’re going to take my eye out and then you scratch away the cataract and then you put it back into my head. We want to avoid things like that.
So some conditions require a bit of a more real world explanation. Take glaucoma, for example. Most people can’t explain what is glaucoma. But if you try to explain it in terms of a water tank, everybody knows what is a water tank. And so water flows in, water flows out. What happens if the outlet gets blocked and the water continues to flow in? Well, the patient will say, “Well, of course, the increased pressure within the water tank and eventually it could burst.” Well, that’s what glaucoma is. So the way we’re going to treat this is either by fixing the old one, outlet, or by putting a new one in. This is the kind of explanation which I think anybody, in any situation, can understand.
As I said, we have two sections, one for adult one for pediatric. Pediatric, the conditions are often the same, but the messages are very different. So in the pediatric section, we have for example, an explanation as to why it’s so important for pediatric cases to be treated very quickly, we then go through all of the different conditions that you have in children, and then we also have things like this. And I know this may be a bit of shock to some people, but that really was our intention. I never want to see a case again, and I’ve seen them, where a mother brings in a child with a white disk and she’s told your patient has a retinoblastoma, this is a tumor in the eye. And then they come back a year or two later and now what could have been treated easily looks like this or you’ve even had enucleation necessary.
So it’s only through communication, through screening, can we prevent this from happening. Of really making the families of these children understand that it’s important that when you come in here, you never let it progress to this or to this.
At the end of The Eye Book, or included with The Eye Book, is what we call The Eye Pad, it’s a block of paper, very simple illustration. And here you can write the patient’s name, and very important, in addition to making any pictures or drawings if you want, you must write the diagnosis. This is one of the most important things, no patient should leave your office without a clear understanding of what is the diagnosis. Because otherwise they will talk to their family members, they will talk to people in the community. And if they don’t have it right, then it will get further away from the truth each time. This way they say, “What I have is called retinoblastoma.” “What I have is called cataract.” Every time they use the correct word, they’re reinforcing the truthful explanation. So this is very, very important that you always make sure, either with The Eye Pad or some other methodology, that the patient has the correct name.
The Eye Book is available not just as a printed book, but it’s also available electronically. In both tablet, in vertical form, and also for computer monitors. And of course, the advantage of the electronic version is that you have this here go back to the index. Which means, at any point, you could just jump from page to page very quickly, without having to leaf through the book to find the page that you want. Also it’s good because it saves printing costs and if we do updates it’s easy to distribute it.
In addition to The Eye Book, we’ve also developed a thing called the Poster. Which basically shows your world should look like this, if it looks like this, or this, or this, visit an eye care professional. These have been produced in various sizes, various formats, from quite small to quite huge. And so people are really free to use it however they feel and of course, like everything else, these are done in local languages, also with local images behind, if necessary.
One of the ways in which we will help you develop skills is we have an online interactive communication platform. And here I am sitting at home in my Jodhpur polo shirt, practicing what it’s like to talk to this father of a child with retinoblastoma, explaining to him what it is and why it’s important. You can get more information about this from Orbis, from us. We would develop local programs for every locality, so that you really have a real life experience of what it’s like to talk to these patients.
What can you do now? What you can do now is discuss this whole issue with your teams, decide who in your hospital would be responsible for communication with patients exactly. I was in a clinic where I asked the patient at the end had no idea. And I said to the nurse, “Well, why doesn’t she know about her operation?” “Well, that’s the role of the doctor.” So I ran back to the doctor and he said, “No, that’s the role of the nurse.” I think you should be very clear about at each stage, who’s responsible?
Then the things I’ve talked about. Decide what is reasonable, what is doable in your clinical setting? Decide what you’re going to adopt now? Begin to practice these skills with your colleagues and give each other feedback.
Communication and COVID, and then we’ll stop. The important thing is that you have to be prepared. Make sure that you know all the latest facts. When you’re with a patient, reinforce good hygiene. Be a good role model. If you wash your hands, then you can say to the patient, “Oh, tell me about, are you able to wash your hands on a regular basis during the day?” Ask the patient if they’re living in a multi-generational situation, which very often they are, and how they’re protecting the people that are most at risk, how they’re coping? Encourage them to ask questions about COVID. And again, demonstrate respect in order to gain their trust.
And as you’re talking to them, think about what are the possible barriers, their financial barriers, their access to travel, their stress levels which will prevent them from having optimal care? And most important, throughout your discussions, always use open questions.
The last thing I’d like to remind you is that communication is a team activity. So make sure that everybody in your care team is informed about these objectives and that they try to practice, and they do practice, these kinds of general skills for communicating. Because at any stage in the interaction, you can either gain trust or you can lose trust. And then if you lose trust early on, you’re going to have to work very hard to regain that trust later in the process.
Final summary. Communication is the best treatment for the misinformation pandemic, communication can ease many of the adverse effects of the COVID crisis, and communication will facilitate patient care and improve outcomes. And if you forget nothing, if you remember only one thing, remember the mantra. Ask questions, listen and then confirm.
Thank you very much, I would like to pass this back over to our moderator for your questions and answers.
[Neha] Thank you, Ken. So you know generally, a very common situation here in India, that I know is, and probably in a lot of other countries also, that the number of patients, as you just described earlier in the presentation also, there’s a long queue of patients waiting for a particular doctor. So with that little timeframe that a doctor has, how do we improve the, how do we do all the things? Manage to do the ask and listen?
[Kenneth] It’s an excellent question. The alternative scenario that I showed really, almost all of the things there. This idea of it takes the same amount of time to read the patient’s chart before they enter as when they’re sitting there. So if you get in practice of reading the chart and then saying, “Okay, next patient, please.” The patient comes in, again, while the patient is sitting down, to stand up and to introduce yourself doesn’t take any more time.
So a lot of the things that we talked about, really, if you incorporate it into your practice. Again, when the patient sits down in front of split lab, to explain why you’re doing this or when you pick up your torch to shine it in the patient’s eye, or whatever it is that you’re doing, to be saying to the patient, “This is why I’m doing this test, is that okay with you?” doesn’t add extra time. So I think the important thing about this opening part is that a lot of these things do not actually increase the amount of time you’re with the patient.
This whole business about the waiting times, I see at some of the other presentations I’ve been watching, discussion about alternative ways of scheduling your patients. So that you don’t end up with hundreds of patients or thousands early in the morning and then by the afternoon there’s nobody there anymore. I think all of us have to work on coming up with better ways of controlling patient flow. But the important thing is that good communication does not have to take more time. And if you incorporate these things into your interaction with the patients, you will, at the end of the day, saving a lot of time in terms of general patient care.
[Neha] Thank you, Ken. Another person has also asked, “Is any particular advice for communication with the colleagues as well?”
[Kenneth] Oh, with colleagues?
[Neha] Colleagues in hospital, yeah.
[Kenneth] Yes, this something very important. This is a bigger question. This is something about establishing, it’s a cultural issue. And if you establish a culture that values communication within your teams, that’s the very first thing. That’s the most essential, you have to start with that. And this is something that has to come from the top of your organization. That having this flow of communication that is open and also, a very big thing, is that again it’s a two way thing. If you treat, if the doctor talks down to the nurses, nurses also have to feel confident that they can say to any doctor, “Sir, this is not the right patient.” Or, “Gee, we’ve discovered something else that you haven’t considered.”
I think you have to establish the same kind of dynamic that we’re talking about between doctors and patients, even within your own organizations, because very often it is extremely hierarchical. And the best you can do at making things more flat will help the communication flow. So encouraging people to have this kind of a dialogue, not just I’m instructing you to do this, is the first step. And then after that, it’s really working on these skills.
View communication training as a team activity. And learn when you hand over a patient to another doctor, get feedback. Did you really give all the essential information? Or gee, you’re only giving me the short version of this thing. I need to know more. And that will never happen until you created this environment within your organization, this culture. That people should be free to communicate on an equal level. Just like we’re trying to do with the patient. I hope that makes sense. But until you’ve done that, I don’t think you will ever achieve good communication within your organization.
[Neha] If many individuals get some misinformation or blame the health provider or hospital, especially in this COVID time, in the new normal, there’s a lot of misinformation that can float around. So the hospital has a lot of COVID-infected doctors roaming in the hospital, so don’t go to that hospital, or something else. So how do we, in this case, how do we ensure the effective, and accurate, and positive communication for the hospital?
[Kenneth] Okay, a few things. One, is that you need to have greater cooperation between the hospital, because there probably aren’t that many different hospitals in each town. Between the hospital and the local community, the health officials, the local media, anybody who’s involved, so that you become the authority. And if you introduce yourself… Every hospital should have a communication director. An internal or an external or both. Somebody who’s responsible for communicating with the community. If you already have one, look at what they’re doing. If you don’t have one, create one, it’s a very, very important position. And this person should work with the local community to get, you should be the source. Because these other people are politicians, they’re, these are not doctors. You are the doctors, you should be the source of all important medical information going out to the community.
So approach your communities, anybody who’s out there doing stuff, to make sure that you are the source of the information, it’s coming from you, and that it’s accurate. And it’s at that point you can combat these kinds of misconceptions. The other thing is, a very powerful tool in Switzerland, I cannot tell you how many hospitals we have in my own community here, there’s one on every block. So they’re all competing with each other. And what they have done is they have established regular public seminars or workshops, where specialists go out into the community, the day or the evening or whatever, and they talk about things.
And each of you should be looking to do that within your own communities. Putting out, doing regular, going to local temples, schools, wherever you want, and doing stuff, not just about COVID, but also establishing your credentials, your authorities, the trust. By talking about other things, doing local workshops on eye care, on certain problems, on other public health issues, and also weaving in your messages. Because the more you can do to establish, to show respect within your community, then you will get their trust. And you will be able to combat this nonsense misinformation that’s floating around out there.
It isn’t a one shot process, it’s a cultural thing. Again, it will take time. But I really recommend that you take, that you look at communication as an important part of what you do as healthcare providers in your community.
[Neha] And, of course, The Eye Book, a lot of questions. A lot of people have asked this question, where can they get The Eye Book and from where to download it? And just to add to this. While The Eye Book, of course, seems an extremely important resource for patient counselling, where else can the hospital use The Eye Book, OPD or IPD?
[Kenneth] Of course! To get copies of it, you can download it from Cybersight. If you would like to develop a local version of this, I showed you a list of the countries and languages that we’ve already adapted the book for. But if you’re not a member of any of these, if someone is viewing this from a country that’s not on that list, then contact us at Orbis, explain that you’re interested in doing this thing. We will work with you to adapt it for your local needs. So this is a commitment on the part of Orbis, but also my own foundation, is that we want to work with the global healthcare community, with the global eyecare community.
So if you want a version that’s right for you, contact us, we will work with you to have it not only translated, but also give you the opportunity to have your input into the content as well. We’ve done Latin American faces, African faces, Southeast Asian, Indian faces, Mongolian faces. If you’re not on that list, we’ll also make sure that the illustrations in the book are correct for your local culture, but I think we’re pretty close at this point of having a global one.
Really, contact us, we will work with you to develop an Eye Book for your region. Otherwise you are free to download it from Cybersight in print version, or you could always download the interactive versions either in the vertical for tablets or the, if you want to use it on a Surface or an iPad, or whatever, or from a computer monitor. Those things are available, this is available to the global community.
[Neha] Yes. Just a second, I’m sorry. For the COVID-19 situation, where most of the hospitals and doctors are avoiding the exposure that they have with the patients. How do we, all you answered because the time doesn’t increase, just the management. Do you want to still answer? So in the COVID situation, the hospitals don’t want the patient enclosed, or the doctor-patient interaction time should be as responsible (laughs). So what do you have to say to that?
[Kenneth] Yes, okay.
[Neha] Glad you wore the mask!
[Kenneth] Yeah, I mean. Access to the patients, this is a policy decision. It’s not really a communication problem, it’s much more of policy within the hospitals, about how much access do you want to give to eye care during this time? And what resources you want to devote to each of the subspecialities. It isn’t just true for eye care, it’s true for, there’s everybody that has a pain in his chest, does he need to be seen by a cardiologist?
I think the important thing is to… Yeah, unfortunately, most of the eye camps, these outreach programs have been shut down, globally. So you don’t have access to do pre-screening outside of the hospital situation. In all honesty, I don’t have an easy answer. I don’t see it as much as a communication issue, as a general policy one, on the part of the hospital, as to what you want to devote your resources to. And which clinics want to open and how you want to do it. So I don’t have an easy answer for that.
[Neha] And can you explain some effective methods for telemedicine and communication? For telemedicine?
[Kenneth] I’m sorry, for telling?
[Neha] For telemedicine.
[Kenneth] Oh, for telemedicine! Yeah, this is very, very interesting. Telemedicine is a whole other webinar I would love to do. It’s much more difficult, of course, because you don’t have any of the visual cues. But just because you’re on a phone, doesn’t mean you can’t follow the same kinds of techniques. You know, you just don’t have as much feedback mechanism. But the important thing is to really, even within telemedicine, ask open questions, listen, try not to interrupt the patient on there, and encourage them to give you as much information as possible. Because the only thing you can rely upon is this information they’re telling you over the phone. So the basic strategy doesn’t change, it’s just that you have to put much more focus on encouraging the patient to give you information, audibly on the phone, that would normally be able to get looking at the patient.
I don’t know if you’re using FaceTime, if they’re using just telephones, or what format they’re using, or if they’re using some kind of a Zoom environment. Telemedicine means a lot of things to a lot of people. It can be anything from a phone to extremely sophisticated interactive video system. But the important thing is that the communication strategies don’t really change. It’s just that you have to be more selective in terms of which cues you’re emphasizing.
[Neha] One of the common points that are relevant in communication and where do we need to see a scope of customizing communication? How do we customize communication, let’s say, in the case of The Eye Book. While it is a resource that can be used by itself? Should we make custom?
[Kenneth] Yes, this is not meant to be a one-size-fits-all. The way in which, for example, the information page. If you determine that through the opening question, what is the problem? I’m sorry. Through the questioning, you understand that patient’s disease beliefs, their educational levels, their language levels, try and adapt all of the information in the text here on this page, to what’s appropriate to them. In kind of the language that they want. Stick to the key points. But you have to, each time, think about, is this somebody who works in an office? Or is this somebody who comes off the farm? I use different language, different education. And you will know this from talking to them.
Also the question of, does it really help you to show them the anatomical drawings or will it confuse them more? So depending upon what you’ve learned about their educational level, their linguistic levels, this is meant to be adapted in each case.
Things like the point of view of the patient and what they’re seeing. This is something, the images, everybody will understand. Everybody will understand what this is. And everybody will understand this idea with the water tank, for example. So use these kinds of things, try and really keep it as simple as possible. The important thing about communication. This would all be covered in my workshop, is always think of it as a slow drip and not as a push. This is not a bolus. This is something that you’d want to drip, depending on their interaction.
So if you break it down into chunks, it’s called check and chunk or chunk and check. Break it into small pieces and then each time confirm that the patient has understood. And the important thing, one of the things that I would have gone into the long thing, is at the very end, you have to use something called the teach-back. The worse thing, is that when you say to the patient, “Okay, do you have any questions?” No, they don’t have any questions. But instead at the end, you use what’s called the teach-back, “Tell me what the problem is, tell me what we’re going to do, what you have to do?” And so they have to teach you, it’s the teach-back. Then you’ll be certain that they have understood. And this is important. And if they didn’t get it, then you have to change your methodology and go back and try again to the point where they can give you the important information. Okay?
[Neha] Yes, thank you so much, Ken. Thank you so much for all the time. Thank you, everyone, for participating actively. And thank you. We’ll share the recording with you all. And as Ken mentioned The Eye Book is there in Cybersight, along with the other courses and training modules. Thank you so much.
[Kenneth] Thank you all and stay well. And good luck! These are interesting times.