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 By Neil B. Gailmard, OD, MBA, FAAO, Editor July 6, 2005 - Tip #181 
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Communicating in Subjective Refraction

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Additional Information

I'm sure we all discover phrases that work well in day-to-day patient communication. These special words may make our interaction with the patient more efficient, may put the patient at ease, or may build your image as a caring doctor. In this article, I'll share a few phrases that work well for me along with some thoughts on overall communication during the subjective refraction process.


It occurred to me that optometry relies on communication more than most health care disciplines, because of the importance of the subjective refraction. Granted, all doctors who work directly with patients find verbal interaction important, starting with the case history, but ODs use verbal skills for that and much more. Primary care physicians rely on patients to describe symptoms. Dentists rely on that also, but because they work in the mouth, the patient does very little talking. Perhaps only psychologists and psychiatrists rely on communication more than optometrists.

Subjective Refraction

Isn't it ironic that you almost never see an article in our professional publications on the topic of refraction, even though that test encompasses a major part of what we do? Of course, I know we do much more than that, but even as we assess ocular disease conditions, best-corrected visual acuity is of major importance. Refraction takes a large chunk of the time we spend with all patients, including contact lens care, low vision, pediatrics, and geriatrics.

I suppose the lack of articles on refraction is due in part to the fact that ODs mastered the mechanics of the procedure long ago, but the communication aspects can challenge even the most seasoned practitioner. Often comical, the responses we get from patients as we interrogate them about their quality of vision (under adverse circumstances) can be highly variable. Some people get it immediately, and some never will. Examples of refractive miscommunication include these classics:

  • Doctor: Which is better, number three or number four? Patient: Number two was better.
  • Doctor: Which is better, number three or number four? Patient: T Z V E C L
  • Doctor: Which is better, number three or number four? Patient: Actually, neither one is very good.
  • You can fill in more of your own favorites.
In fairness to patients, we do ask what must seem like some very odd questions. We want to know which lens is clearer, even though they are both somewhat blurry. Our ultimate goal is to make both images look the same, but we keep asking which one is better - and the decision gets harder as we get closer to that elusive goal of equality. We also have a big advantage over patients since we do the procedure 20 times per day and they do it once every 2.3 years.

Digital Refraction

One of the many benefits of computerized refractors is that they can offer two images side by side, which greatly aids communication. The patient does not have to remember the quality of the previous image and the doctor does not have to repeat the options several times when the patient can't decide. It's just easier to tell the clearer image when they are side by side. Of course, computerization is not required to achieve that practical approach... I remember using the Zeiss Simultan test in optometry school, which simply attached to the lens well of any phoroptor and used a split prism to present two images at once. But that's just a museum piece now, although I'm not sure why some inventor hasn't pursued the principle. It was brilliant.

Cardinal Rules of Refraction

  • Simplicity. Avoid long, scientific speeches about refraction and complex descriptions of what you are going to ask. Just ask it. There is a cute story about a man who is asked what time it is, and he responds by telling you how to build a watch.
  • Patience. You will get better results and the procedure will be easier if you don't reveal any frustration you may feel. Always be kind, polite and friendly to the patient even though, at times, you may become a little annoyed. Once the patient senses some dissatisfaction on your part, he or she will become more defensive and distracted from the task, and you end up looking like the jerk. Go slowly when needed and make the choices easier.
  • Encouragement. The more difficulty the patient has, the more encouragement they need. Words like "you're doing fine" or "we're almost done" can be helpful.
  • Speed. Boredom and fatigue can lead to poor subjective responses. Work on your technique so you don't offer more choices than necessary. Don't fog and unfog more than necessary and don't seek reversals you don't really need. A quick refraction is a pleasant refraction.
Favorite Phrases

You may want to reserve some of these statements just for the group of patients who have difficulty grasping the concept of subjective refraction. It doesn't take long to identify people in this group.

  • This statement is my favorite: "I'll have you look through two different lenses. Even though neither choice will be perfect, I want you to say which one looks clearer".
  • If the patient is indecisive, remember to add: "... or do they look about the same? It's always OK if you think the choices look about the same."
  • For the nervous patient: "Many people dislike this test (as you gesture toward the phoroptor), but I'll make it very easy for you, so don't worry.
  • For those who struggle: "Some of these lens choices are very easy, and some are difficult, but that's OK; you're doing fine".
  • For the difficult refractive case: "I'm going to have to ask you lots of questions during this test, but it's important so I can make your vision as clear as possible. Just relax and bear with me".
  • For the impatient patient: "Even with all the examination technology we have in this office, I still like to know your personal preferences, and that's why I do this test. We obtained this information by a computer analysis earlier, but now I want your input".

Best wishes for continued success,

Read Past Tips Neil B. Gailmard, OD, MBA, FAAO
Editor, Optometric Management Tip of the Week

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Send questions and comments to neil@gailmard.com.

Dr. Gailmard offers consulting services to eye care professionals through Prima Eye Group; information is available at www.primaeyegroup.com.

Please Note: The views expressed in Management Tip of the Week do not necessarily reflect those of the sponsor.

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