The Dissatisfied Ophennanmie Patient EDWARD RYAN

I PROPOSE to tell you something of my experience with the dissatisfied ophthalmic patient in what T believe is a typical one-man practice in the east end of Collins Street, Melbourne.

I must make it clear that I do not refer to these surgical or medical disappointments which sadden us all, but to those patients who return to complain about their spectacles-that potent and recurring source of anxiety and frustration which, I suspect, is the reason why so many otherwise balanced people generally assume that every oculist over 60 is either irascible or eccentric.

My comments, of course, are directed primarily to my junior colleagues, in the hope that this melancholy list will give them encouragement and wisdom. My mature brothers, of course, know it all, but I trust during this address they may wake at times and allow with a wry smile, “ Yes, it happened once to me, but so long ago”.

I need not stress how important the prescription of glasses still is. J. R. Anderson, that most distinguished oculist, declared his enormous practice was founded on the accurate prescription of glasses. I n my own practice, and apparently in the practices of others who have been kind enough to help, only 1% to li% of patients come to surgery ; the rest are largely spectacle problems. ,

Some years ago, then, I resolved to note down without prejudice and with complete honesty all those who were dissatisfied. I am glad I did so, even though the figures are sobering and a t times disgraceful. I will not bore you with my opinions. You will see the facts and judge for yourselves. I must add that I ask all patients to return for checking of spectacles, and most of them do. When they complain, they are interviewed, and no matter how trivial their comments they have been included in the list you are to consider.

It seems to me there are two philosophies in the prescription of spectacles. Each has

its successes and failures. The first is the authoritarian (( Captain Bligh ” approach. The patient is told ((Wear those glasses or else ”, but though this calls for a tempestuous approach not conducive to equanimity, it can nevertheless be effective and time-saving.

The second is the meticulous conscientious approach. I knew one doctor who always did her post-mydriatic tests twice. Here again it is a useful method, but nerve- wracking and time-consuming.

I suspect there is a classical via media, but I must say I have not found it yet. I envy many of my colleagues who can say ‘( Well, it’s your fault. You chose them ! ”

So now to the facts. The cases are not dissected in depth, but consideration of background factors, such :ts marital state, size of bank balance, etc., though often important, cannot be encompassed in ten minutes or so. The bare outlines are therefore listed .

I report on ten years of practice, during which 476 patients out of nearly 70,000 returned to complain. I was surprised to see that the ratio of females to males was 2 : 1, yet in my practice the attendance was in the ratio of (females to males) 9 : 1.

Total

Males . . . . . . . . 153 Females . . . . . . .. 323 Clergy :

Females 2 6 1 . . . . :. .’ Males 61

Armed Forces : Enlisted 1 1 . . . . 6 Officers 5 1

Perhaps the better psychologically adjusted male seeks the prompt attention of an optometrist, and those who do see the doctor are often disturbed.

I always had the impression that they rarely if ever complained, and if ever a frail old sister returned I felt as if I had been bitten by a rabbit. I also thought the males were harder to satisfy, but the reverse was true, even allowing for differences in total numbers. One per cent of the male clergy complained ;

The clergy figures also surprised.

AUSTRALIAN JOURNAL O F OPHTHALMOLOGY 86

3% of t,he females. Deans, sister superiors, heads of colleges and monasteries, and bishops totalling 16 in all produced nine unsatisfied clients.

The armed services caused no surprise. Of some 2,100 there were only seven complaints from the L L other ranks ”, but there were six from colonels, generals, group captains and squadron leaders.

Thus you will observe the higher the rank, either in the forces or the clergy, the more likely they will worry about their glasses.

I

will see, after a promising start in January, the curve rose sharply to mid-June. Perhaps the bleak Melbourne winter disturbed the oculist’s balance or the patient’s temper. And in December, I suspect, patients have more on their minds than cluttering up the oculist’s rooms.

After brooding over the case histories of these patients and sifting the evidence without prejudice, it seemed that of 467 disgruntled patients, in at least 159 the doctor was a t fault, in 70 the optician had made a mistake,

I 1961 1961 150~- 1965 1966 1967 196# 1969 1970 Dm

PIQURE 1.

I had fondly hoped that the years would have brought tolerance, skill and wisdom. Alas! Not so. I am ashamed to see the curve of discontent, after a gratifying fall, climbed inexorably to its original height and stayed there.

I suspect hurry and over-confidence choked OE the effort to do better.

in 72 the patient was to blame (I think), and in 56 lack of communication was the cause, though of course it is a reflection on the doctor’s awareness and sympathy, and I feel these figures must be added to the L L doctor’s dilemma ,’.

May I deal with the doctor’s mistakes? It is certainly a sobering list.

I had always imagined that troubles Old ladies, I should know, are happier preceded the holidays and that improvement with their old glasses. I altered too many. followed. This is only partly true, and you Mistakes in copying out a prescription must

THE DISSATISFIED OPHTHALMIC PATIENT 87

occur, especially when chatting with a patient, but they should not. The careless mistakes were nearly all “ hurried careless ”, as with one Sister Patricia, of whom I have 30 or so

Doctor’s fault . . . . . . 159 Optician’s fault . . 70 Patient’s fault, i.e. cr iz i , con-

fused, resentful, etc . . . . . 72

on my books. I posted her a prescription, but when she returned a year later with a gentle reproach it was the wrong Sister Patricia altogether.

Dmlor’e Fault

Bad writing . . . . 10

Prisms left out . . . . . . 5 Miscopied on to scrip . . 13 Elderlv female’s faithful alas& 8

Cylinder left out“ . . . . 4

Careless . . . . . .- .. 28

The opticians’ faults were predictable. I think we all know that bifocal-segment heights are a potent cause of distress, but the reversal of lenses was of interest.

Lack of communication was a most potent cause of dissatisfaction. I must say the fault was the doctor’s almost always. Our ophthalmic forefathers thundered out of the past in the classical text-books that too strong a plus

Eye disease. Here again I think that I was often wrong for not warning the patient that, despite glasses, at 80 he would not SW as well as a t 18. How often they say, “ Doctor, the glasses your father ordered in 1910 were much better than yours ”.

Eye Disease8

Cataracts . . . . . . 6 Macnlar changes.. . . . . 7 Venous thrombosis . . . . 2 Meibomiau cysts . . . . 3 Nystagmus . . . . . . . 2 Cyclitis . . . . . . 1 Vitreous opacitiei‘ . . . . 3 Retinopathy . . . . . . 3

Have you noticed how visual acuity can be affected by a chalazion? Though, in one case, the co-existence of considerable pain was due to retro-bulbar neuritis later detected by a colleague.

Finally, there are the collection of patients who return more than once. Of these, three

Patients

Two or more visits with complaints 16 Bizarre complaints : . . . . 34

Schiloids . . . . . . 2 Breakdown . . . . 3 Bereavement . . . . 5 Relative’s glasses . . . . 2 Dirty glasses . . . . 4 Bad t,emper . . . . 3

had exophthalmic ophthalmoplegia, two had keratoconus, and six had “ high cylinders ”.

correction of presbyopia was the The list is bizarre: Optician’s Fault

Lenses reversed . . . . . . 2 Wrong scrip . . . . 16

Aphakic O.C. wrong . . . . 5 Ill-fitting frames.. . . . . 19 Altered shape :

Bifocal . . . . . . 4 Trifocal . . . . . . 2

Rifocal wrong hiight . . . . 27

commonest reason for dissatisfaction. I did not believe them. Now I do. But some- times, as when the patient is led in, largely blind, by sorrowing relatives, only to be found

Lack of Cmmunieatim

Typing distance . . . . 19 Piano . . . . 5 Bifocals not expiined .. ,_ 5 Language barrier . . . . 5 Librarians . . . . . . 4 Welders .. _ _ _ _ . . 2 Preacher . . . . . . . . 3 Nusicians . . . . . . 4 Seamstress . . . . . . 2

Total . . . . . . 56

wearing readers, or when the elderly spinster complains that she cannot read with her “ street-walking glasses ”, well, I feel the practice of refraction is not unrewarding.

A chiropractor said the glasses were no good, Grandma said they suited her as well a6

Two needed cleaning. One female was dissatisfied with her

A man said the golf balls looked too small. Another said the ducks flew too fast on

Some (three) were angry at being kept

One woman’s husband left her because of

One fell and had to take a taxi. I got

The Greeks found my glasses mused

The Italians were too vain.

THE MESSAGE 1. Beware of over-confidence, fatigue, hurry,

ill- temper. 2. Find out why glasses are needed. 3. Explain how they are to be used. 4. Write clearly. 5. Check the glasses.

her grandchild.

honeymoon.

opening day.

waiting.

her glasses.

the bill.

impotency.

88 AUSTRALIAN JOURNAL OF OPHTHALMOLOGY