Effective myopia management requires more than just clinical expertise. Technical skills are essential, but the patient-provider relationship matters even more. Treatment plans are more likely to be followed when the word trust defines the relationship.1
To create a future where all children with myopia receive proactive myopia treatment instead of reactive solutions, providers must create trust-filled relationships where patients and parents fully embrace our myopia management plan.
Incorporating principles of the “Building Trust” initiative
The American Board of Internal Medicine’s (ABIM’s) Building Trust initiative, which launched in 2021, outlines specific ways to enhance the provider-patient relationship.2 As eyecare providers, we want loyal patients who trust our treatment plans.
The Building Trust initiative outlines five dimensions of trust:
- Communication
- Competency
- Comfort
- Cost
- Caring
Embracing the 5 Cs of trust building
The five Cs relate to every patient encounter but are especially important in orthokeratology (ortho-K). Because the success of an ortho-k treatment plan involves much more than simply filling a spectacle prescription, the relationship must be stronger and more trusting. Each of these can be utilized during every encounter, from the initial myopia control consult to the lens application visit and subsequent follow-ups.
Communication
Communication is the first critical element to build trust. It is woven through every interaction with the patient. Communication encompasses word choice, tone, body language, demeanor, and even the physical appearance of the clinic—all of it matters.
The initial impression of the clinic, staff, and provider is essential to start the process of building trust. Be friendly, genuine, and listen attentively. Don’t rush a good case history to “get on with the exam.”
Tips for clear communication include:
- Spend time discussing interests, goals, expectations, and concerns.
- Explain myopia and why it matters before introducing treatment options.
- Allow ample time for questions.
- Share evidenced-based safety data.
- Before treatment starts, inform patients about potential adverse effects and solutions should they occur.
Optimizing communication around myopia management
After laying the initial foundation of trust through good communication, then explain myopia in words that a child and parent can understand and why myopia matters. Next, review the benefit of proactive myopia treatment (such as ortho-K), and be prepared for questions. Trust that parents will always have questions. Often, children will as well, though they may be too shy to ask them.
Commonly encountered questions include:
- Why haven’t I heard about this before?
- How does the treatment work?
- Are lenses safe for children this young?
- Why can’t my child just wear glasses?
- Which treatment do you recommend?
- Could we wait until next year?
- How much will it cost?
Despite a busy schedule, avoid the temptation to rush through the questions to get on to the next exam. If the patient doesn’t feel listened to or understood, trust diminishes. Taking ample time during the myopia control consult is worth the investment, as it shows the patient that the provider is attentive to their concerns and committed to their care.3
In addition to fielding inquiries, it is vital during this first visit to give guidance about possible complications. The informed consent for lens wear must include the possible complications. Communicating possible problems and subsequent solutions demonstrates dedication to the patient’s long-term well-being, not just the transaction. If we gloss over possible problems, patient trust could diminish, jeopardizing adherence to our myopia treatment plan.
Competency
During the myopia control consult, providers establish competency by confidently sharing evidenced-based safety data, success statistics, and treatment options with their full range of benefits and drawbacks.
Sample conversation
“Ava, you did a good job on your eye exam today. Can we talk about what it all means now? Your eyesight is getting blurry because of something called myopia. Myopia means your eye has started to grow too big, too fast. The reason that matters is it makes it hard to see ________.” (It’s essential to reference something specific that the provider heard during the case history instead of just saying “far away.” This shows the provider is listening and cares about the individual.)
Once myopia starts, it progresses for several years, but the good news is we have several proven methods that can help you see the _______ better now (use the same reference from above) and slow down the worsening of myopia. I’ll start with the treatment I think will be most effective for you, and then we’ll consider the other options as well.”
In addition, trust increases if we communicate the side effects and safety concerns prior to anything adverse happening as opposed to explaining it afterward.
Using the follow-up to convey competence
During the first consultation, it is our words that promote our competence; lens application and removal training is the first chance to demonstrate it. Parents might be skeptical if their child can effectively apply and remove the lens or wonder if the child will allow the lens onto their eye. Successfully applying and removing the lens for the first time adds another element to the competence element of trust.
The first follow-up visit is my favorite. I love to see the improvement in the child’s unaided visual acuity and the parent’s awe at the difference. Over time, visually demonstrating the reduced rate of axial elongation confirms the value of the treatment and demonstrates competence in managing myopia.
Along with acknowledging progress, follow-up visits will inevitably require addressing concerns, which could be as straightforward as a lost lens or as complicated as microbial keratitis. Clinicians must possess calm and competency across all situations. Being prepared for any complication and knowing how to resolve it demonstrates competency and promotes trust.
Sample conversation
“Jackson, thank you for telling your parents about the pain you felt in your eye. You and your mom did the right thing to come in right away, so we can look at your eye and help it feel better. (Then turn to the parent.) I’m glad you came in today, we always want to check Jackson’s eyes right away if something is wrong.”
When a lens is broken or lost, it’s imperative to have a plan in place from the beginning for this possibility. If the provider or clinic seems unprepared for this moment, trust decreases. The parent’s first concern in this scenario is to make sure their child can see. Be sure the plan addresses their chief concern and is implemented the same day.
Adverse events should be rare but will happen at some point. In the VOLTZ study data, the top five specified reasons patients discontinued the study were unsatisfactory lens fit, corneal infiltrates and/or erosions, corneal microcysts, corneal staining, and allergic conjunctivitis. A small group discontinued lens wear due to unspecified ocular health problems during COVID-19.5
While not observed in the VOLTZ study, microbial keratitis is the most concerning adverse event in contact lens wear. The provider must be prepared to treat this condition or refer to the appropriate provider as required.
Comfort
In the realm of ortho-K, comfort can be thought of in two ways: creating a comfortable and safe environment during appointments (consult, fitting, training, and follow-up) and making certain the lenses themselves are comfortable for the patient.
To achieve the former, take steps to make the office inviting and make certain all staff are friendly and warm in demeanor. Throughout the appointment, practice patience and be encouraging, especially while individuals are asking questions or voicing concerns. Practice active listening with open body language and reassuring gestures.
During training, avoid minimizing how challenging or intimidating it is to apply a lens. Never force a lens onto the eye. The fear of the lens can be intense for some patients, and forcing it against their will erodes the child’s emerging trust. It’s better to be comforting, encouraging, and patient.
Upon follow-up, if the concern is about lens comfort, acknowledge it, and thank the patient for their honesty. At the training visit, we should have prepared the patient for some initial discomfort, but, after the first week or so, this shouldn’t be part of the ortho-k experience. Lens discomfort occasionally needs a design change but usually requires revisiting the proper steps for application and hygiene.
Inspect the lenses through the slit lamp to assess the lens surface and demonstrate cleaning the lenses in the office again. Ensure the patient is using the prescribed lens cleaner and not substituting it with something else. Review proper hand washing techniques, and ensure the hands are fully rinsed and dried properly with a lint-free towel.
Cost
Likely, during the myopia control consult, the parent will inquire about the cost of the treatment. If the clinic honestly and plainly communicates the cost, highlights the value of the treatment being provided, and explains the return on investment, it can go a long way toward building trust. Be transparent about the cost of treatment, both what is included and excluded.
Unexpected costs, like charging for a replacement lens if the parent thought all lenses were included, reduce trust in the relationship. Parents should be informed of additional costs that could accrue under certain circumstances, such as if a lens is lost or broken, or if an office visit is required for a black eye suffered at softball practice.
Pearl: Make certain the parents have a written explanation of the costs and what is not included. Treatment goals and safety information are best included in a written informed consent document. Financial details and clinic policies should be included in a written ortho-k agreement.
Caring
Caring is defined by Merriam-Webster as “feeling or showing concern for or kindness to others.” Each appointment—myopia control consult, ortho-k fitting, and subsequent follow-ups—affords the chance to demonstrate caring. During every encounter with the patient, be empathetic and understanding.
Do your best to always make them feel heard and respected. Acknowledge a parent's fears, take time to listen, and assure them you will go above and beyond to give their child the best care and vision possible.
Conclusion
Of course, when managing myopia, technical skills in lens design and resolving problems are required, but building trust between patient, parent, and provider is also critical to the success of the myopia control journey.
Look for ways to build more trusting relationships in each interaction by using the 5 Cs: communication, competency, comfort, cost, and caring.
