Article Date: 8/1/2009

Why Patients Hate Refractions … And What You Can Do

Why Patients Hate Refractions … And What You Can Do

By understanding the patient's "pain points," you can provide a better refraction.

GULROOP HANSRA, O.D. Downers Grove, Ill.

Watching Brian Regan's hilarious DVD, "Walking on the Moon," we get a glimpse of what was running through the comedian's mind during his last visit to the eye doctor. Not only is his narration entertaining, it is actually very similar to the thoughts and feelings shared by patients in various focus group studies. Although the primary reason patients visit their eye care practitioners is to see more clearly, most do not understand how doctors arrive at their prescriptions for vision correction. There exists a great deal of anxiety about the refraction. Many patients feel if they choose the "wrong" answer on the test, it can lead to a poor prescription. In essence, they feel the refraction is very arbitrary, and not scientific.

Interestingly, many patients associate the overall thoroughness of the eye exam with their ability to see clearly through their new glasses or contact lenses. Ironically, doctors associate quality with their ability to perform an accurate refraction (not their patient's experiences with new eyewear) and most O.D.s feel extremely confident in their clinical abilities in this area.

So how do we alleviate patients' concerns about the refraction and improve their perception of the quality and thoroughness of the eye exam? The answer is not a new clinical protocol for performing a refraction, nor is it a new type of phoropter. It is however, better understanding the patient's pain points during the refraction and addressing them through improved communication between doctor and patient.

The power of communication

In surveys, patients often rank strong interpersonal skills higher than good medical judgment. In Working with Emotional Intelligence (Bantam, 2000), psychologist Daniel Goleman concludes that many doctors lack empathy. After observing more than 100 refractions, and hearing feedback from both patients and doctors alike, I would agree that optometrists need to improve the way they communicate during the refraction. The good news is that by recognizing the issues and adapting better communication skills, we can improve these perceptions relatively easily. Here, I'll discuss the main pain points and offer solutions.

What's going on?

On Brian's trip to the doctor, the doctor turns the lights low and slides this big thing in front of his eyes … and he wonders, "Are these my glasses?"

As absurd as this sounds, patients don't know what to expect during an examination. The patient perceives you as being aloof. Imagine turning the lights low, covering your eyes, and trying to have a conversation with someone. Awkward!

ISSUE: Patients don't understand the refraction process. And the doctor often lacks empathy when performing a "process-driven refraction."


► Help the patient to understand the refraction process. It can be as simple as, "Brian, the first thing I am going to do is test your distance vision, then your near vision, and afterward we'll do a thorough health evaluation."

► Be there and be present. Give the patient face-to-face directions prior to sliding the phoropter in front of their eyes.

Flunking the "one or two" test

Brian gets very nervous before the refraction and worries that if he "flunks" the "one or two test," the doctor will send him home with a big pair of "Coke bottle glasses."

At one point when the doctor asks which is better, one or two, Brian says, "They look just about the same."

To which the doctor replies, "Now, why would I waste your time and mine, by making them the same?"

ISSUE: Patient's don't understand how we calculate their prescriptions. They lose confidence as the refraction goes on, due to choices going from distinct to ambiguous as cylinder is bracketed.


► Help patients understand that the refraction is one of several ways to help you determine their prescription, along with the auto-refractor, habitual prescription, visual acuities, history, and subjective refraction.

► Communicate to them about what to expect and inspire confidence:

"Brian, I am going to give you a couple of lens choices, one or two. What I am doing is bracketing — or refining — your prescription. Initially, one and two may be very distinct, and as we get closer and closer to the endpoint, one and two may look just about the same, and that actually is a good thing. I will check and double-check your responses constantly, and I won't allow you to make a mistake. If I go too fast or slow, let me know — I can speed up or slow down. What questions do you have for me before we begin?"

► Continue to encourage and inspire confidence. Instead of saying "good" in a monotone voice after each choice, cheer patients on and use descriptors that inspire confidence and encouragement, such as "very consistent!" or "great, we got a reversal, just what we were expecting."

When reaching an endpoint, let the patient know you are in control and know exactly what to expect. For example:

"Now Brian, these lenses might look just about the same, so try your best to tell me which is better, and if they look the same, that's okay."

The refraction celebration

One of the funniest moments comes when the doctor is evaluating Brian's versions and asks if anyone has ever told him that his one eye sits a little bit higher than the other.

"No, is that a problem?" asks Brian.

"No, it doesn't effect your vision, I just thought you might want to be self-conscious for the rest of your life," replies the doctor.

ISSUE: Many doctors don't take the time to celebrate the most important priority — arriving at the patient's best-corrected visual acuity. We don't make patients feel empowered.


► Celebrate with patients when they do hit their best-corrected visual acuity. Imagine, many of these patients have been hypersensitive about their vision their entire lives. These patients, in particular, hate the refraction. Many cannot see the clock in the morning. But through your refraction, you show them that you can provide a correction that allows them to see 20/15. You're now the best doctor they've ever had. Be sure to take the time to really celebrate it:

"Awesome job, Brian. That last line you read is 20/15, which is actually better than 20/20."

► Make patients feel empowered, allow them to become a part of the process as opposed to just doing "stuff" to them. This will reduce remakes as you gain buy-in with patients.

When demonstrating the correction, say:

"Brian this was how you were seeing … and this is what we came up with today. Will that work for you? Would you like to go home with this prescription?"

The psychological tool used by the doctor is called "cognitive-dissonance," which, in a nutshell, means that it is human nature for people's actions to be consistent with their words.

Close with details

During your summary, explain to the patient what you are prescribing and — based on their lifestyle needs — why you are prescribing it. Tell them in detail what to expect as far as adaptation and reassure them if there are any problems, you will be there to help.

Find your coach

One thing I've learned over the years from the greatest sports figures, such as Michael Jordan and Tom Brady, is that no matter how great one is, everyone needs a coach. Therefore, take the time today to have someone observe you in the exam lane, or perform an exam on an associate. After the exam, ask for specific feedback on what you did well and what you could improve.

Continue with a couple of different approaches and ask which worked better and why. You'll be surprised what your "coach" has to say. Make observation and feedback a best practice.

If we all took the time to improve our communication skills, maybe Brian's next routine would be about his visit to the restaurant, as opposed to the eye doctor.

Now onto Brian's stomach ache and his visit to the emergency room … OM

Dr. Hansra is Director of Eye Care at Luxottica. Send e-mail to

Optometric Management, Issue: August 2009