The role of patient counsellors in increasing the uptake of cataract surgeries and IOLs
This article gives the experience of the eye hospital of the Vivekananda Mission Ashram, where we have found that patient counsellors make a major contribution to increasing the uptake of cataract services, particularly intraocular lens (IOL) surgery.
Patient counselling is an important part of medical or surgical management of a disease. Every patient should know about the nature of the disease and the benefits of the treatment suggested by the doctor. In industtrialised countries this part of treatment is adequately managed but in developing countries patient counselling is very much neglected. The reason may be the larger volume of patients per doctor who finds it difficult to explain everything to the patient to take away anxieties and apprehensions. Patient counsellors are very useful in providing this service.
We have found it useful to select for counsellor training people who have been observed at work for at least six months. This gives the employer a chance to assess the worker’s attitude towards patients and his or her interest in learning basic aspects of ophthalmology. Keeping these aspects in mind, ophthalmic nurses and field workers are good choices for the post of counsellors because they already have a basic knowledge of common eye problems and are exposed to the community to some extent. A less experienced person may also be found suitable for the job and can be trained in the hospital and at outreach camps.
The training includes theoretical and practical parts. In the theoretical part trainees are taught the basic anatomy and physiology of the eye using models and charts, with some information about common eye diseases like conjunctivitis, corneal ulcers, cataracts, glaucoma, diabetic retinopathy, age-related macular degeneration, common refractive errors, etc. Special care should be taken to give clear information about the advantages of intraocular lens implants (IOLs) over conventional aphakic corrections.
In the practical part, trainees are shown cataract extraction with IOL implantation and other common surgeries. Videotapes, if available, should be used to teach them. Otherwise they can observe surgery in the operating theatre. They should watch how local anaesthesia is given so that they can inform patients about general surgical procedures. The trainees should observe the ophthalmologist and experienced counsellors in the outpatient department to learn about the commonly asked questions and how they are answered.
Although the prognosis for vision should always be discussed by the ophthalmologist, trainees should also be aware of the visual prognosis in certain conditions like diabetic retinopathy, age-related macular degeneration and the glaucomas. In this way, while assuring the patient of the need for surgery or treatment, they would not be inaccurate in assessing the prognosis for visual recovery.
Attending outreach camps is also included to give trainees exposure to work in the community.
Counsellors sit at their desks in the outpatients’ department with a model of an eye, specimens of cataract, IOLs, one pair of +10 dioptre spectacles and information materials on common eye diseases printed in the local language. They first go through the doctor’s advice in the case record and try to answer the patient’s questions accordingly. In developing countries patients usually prefer conventional cataract surgery, which costs less than extracapsular cataract extraction (ECCE) with IOL implantation. Counsellors, in the hospital setting, try to change their ideas by showing them the heavy, cosmetically unacceptable + 10 dioptre spectacles, and then telling them of the other advantages of IOL implantation. They also mention that recurrent expenditure to buy aphakic corrections works out costlier than paying for an IOL. They inform the patient about the common minor post-operative problems, including the future possibility of posterior capsular opacification, and their remedies.
Counsellors should allow sufficient time to discuss different issues raised by the patient, including personal problems. Some patients, for example, may prefer to postpone surgery until the next harvest season in order to have enough money to pay the costs involved. The counsellor examines the case record to see whether the surgery is urgent and answers accordingly. It is always advisable to discuss problems with the ophthalmologist whenever the counsellor feels it is necessary.
Apart from surgical aspects, counsellors tell patients about the importance of regular medication and follow-up in glaucoma and maintenance of personal hygiene.
In the inpatients’ departments counsellors visit every patient and ask them about their problems so that they can give better advice as to the patient’s future. Patients who undergo surgery are requested to motivate other villagers to come forward for surgery and also to visit the outreach screening camps, if held nearby, to encourage others attending the camp.
The outreach screening camps may be the first opportunity to motivate patients for surgery and then counsel them in favour of an IOL implant in the hospital. When the benefits of surgery are well explained most patients agree to undergo surgery. Counselling becomes more effective when patients’ relatives, who may be paying for the surgery, also take part in the discussion. Counselling becomes easier if somebody who has already undergone surgery is present in that particular camp. In the camps, there is an opportunity for group discussion. Patients are also given information printed in the local language describing the advantages of cataract surgery with IOL implantation. Some eye hospitals take patients for surgery on the screening day itself but, where the patients are admitted a few days later, the information leaflets help them to think over the matter and reminds them of the issues discussed with the counsellor.
Counselling is very much needed by patients who have glaucoma, especially primary open angle glaucoma, because these patients do not find any apparent benefit from either medical or surgical treatment. This is probably the toughest job for a counsellor in a rural setting. Counselling is the only way to ensure compliance with regular medication, if given, and periodic follow-up.
In the developing world many patients may be visiting a doctor for the first time in their lives, often when they are very old. These patients particularly benefit from counselling. Very often counsellors are more effective motivators than doctors.
Additional benefits to the eye department
Counsellors give very good feedback to the hospital management regarding patient care facilities. They talk directly to the patients about their problems. They can suggest necessary modifications in services, and they are often the best people to propose the kinds of patient information that is needed.
In some parts of the world, especially in northern and eastern parts of India, there is a preference for undergoing eye surgery in the winter. The mistaken belief is that the results of surgery are better at that time. As a result, the eye wards remain under-utilised in summer and over-crowded in winter. It has been seen that effective counselling of patients can change this seasonal preference, and the hospital can perform uniformly throughout the year.
Vivekananda Mission Ashram
Vivekananda Mission Ashram is a missionary welfare organisation, named after the Indian philosopher, Swami Vivekananda, which has been working in rural Medinipur District, West Bengal, since 1962. In the beginning the Ashram established general education institutions, particularly for girls. Later they established a residential school and vocational training and rehabilitation centres for the visually impaired. Encouraged by the success of these institutions, a community based rehabilitation (CBR) project was set up in 1994 with the support of Sight Savers International. The Ashram felt the need to establish an eye treatment centre to support the work of the CBR project, and, in May 1994, a 30-bedded eye hospital (Netra Niramey Nitekan) was built which started functioning in April 1995.
From the outset, importance has been given to patient counselling. Initially doctors spent a lot of time explaining everything to the patients. Gradually counsellors were trained from among the CBR field workers, and they took over the job of explaining. The catchment area of the hospital is approximately 4.5 million people living in the eastern part of the district. The number of beds has increased to 66, and the volume of work has increased dramatically since the eye work started.
Good counselling has been one of the prime contributors behind this success. In 1995, 50% of the 377 cataract operations done between April and December were ECCE with IOL; by 1996 this figure had increased to 78% of 1,714 cataract operations performed over the 12 months. Data for the first nine months of 1997 show that 90% of the 2,406 cataract operations done were ECCE with IOL (Fig. 1).
Common questions asked by patients
1. Regarding cataract surgery:
a. Can I avoid surgery since I’m already very old?
Explain the possibilities of hypermature cataract and lens-induced glaucoma.
b. Is there any eye drop to cure cataract?
No. Don’t spend money in buying expensive ‘anticataract’ eye drops, which claim to be effective.
c. Can I expect clear vision after surgery?
The counsellor should carefully go through the case sheet and find out whether there is any comment in the record regarding visual prognosis.
d. Can I wait until next winter for my surgery? I believe wound healing is better in the winter season?
Advise that there is no seasonal difference in the success of surgery.
2. Regarding IOLs in hospital:
a. Why should I go for this newer technique?
Explain the advantages of IOL implantation over conventional aphakic correction.
b. How long will the IOL last in my eye?
Usually life long.
c. Is it necessary to change the implant again?
d. Will the implant get displaced if I do a lot of physical labour?
No, but you should be careful about injury to the eye.
e. Will it cause irritation inside my eye?
f. Do I need to wear spectacles after IOL implantation?
It depends on your personal needs and occupation. For example, reading spectacles may be required. Even if you need spectacles they will not be thick and heavy.
Counselling improves the quality of service and builds up the confidence of patients, which in turn increases motivation in the community to receive eye care services and to accept IOL surgery. Certainly pseudophakic patients are much more satisfied customers than aphakics. This helps the organisation to attain both the trust of the community and financial viability.