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The subjective manifest refraction may be one of the most disliked tests in an eye exam - by both patients and doctors. We all know how critical it is for a good visual prescription and as a diagnostic aid in the eye health evaluation, but the test can make patients uneasy, and it consumes a great deal of doctor time in most practices.
Sure, there are computerized refractors, and some optometrists are delegating refraction to technicians, but no matter how we change the lenses and no matter who changes them, the patient still must decide which is better... one or two? It's easy to forget how the patient perceives this test, because we eye care professionals are just so close to it. After all, we've performed the test thousands of times, but patients may have only experienced it a few times - or perhaps never before.
This week's tip is to simply reconsider the patient's point of view of the subjective refraction - and to make the test as easy and quick as possible.
First, let's acknowledge that the test is unpleasant because, by definition, many of the lens choices are difficult to make. In fact, the closer we get to the correct Rx, the closer the lenses seem to be. When we are at the final sphere point, the next lens usually looks exactly the same as the previous. When the cylinder axis is correct, the two choices offered look equally distorted, although they will tilt in opposite directions. Sure, we can say "... or they may look the same", but the patient is trying to see subtle differences, and they rarely look exactly the same.
Here are a few points to consider:
Obtain a good objective autorefractor and have your assistant perform the test on every patient. It is a huge time saver.
I have my technicians dial the patient's previous habitual Rx into the phoroptor before I enter the exam room. It is a good starting point. If the patient does not have previous glasses, we dial in the autorefractor result.
Be kind during the subjective - don't go too fast and don't develop an impatient attitude or tone of voice. Tell patients they are doing well.
Joke about the test occasionally - admit that most patients find this test the worst part of the exam, but that you'll try to make it easy. "Even with all our technology, I still have to ask you which is better - 1 or 2?"
If a patient is struggling with decisions, acknowledge that you are asking a lot of questions and that it is OK if it seems difficult. Give feedback about how much longer the test will take.
Make an effort to keep the subjective brief.
Try to make choices easier by clicking two steps at once at times. Or purposely test off axis or power to get a reversal back - it's easier to make a lens choice when they are not equal.
Use large enough acuity lines for the patient's ability - it may be easier to make choices with a slightly larger letter size.
Best wishes for continued success,
Neil B. Gailmard, OD, MBA, FAAO
Editor, Optometric Management Tip of the Week
Dr. Gailmard's new book, Practice Management in Optometry: A Blueprint for Success Based on the Optometric Management Tip of the Week, is now available on Amazon.