Planning for the Examination
The visit of a deaf patient in any medical office requires some extra planning to make sure that the quality of the examination is the same as that of hearing patients. If the visit is the first visit in that particular office and if the referring doctor does not give information on the type and level of communication used in previous examinations, it is advisable to confirm the appointment via TDD (telecommunication device for the deaf). In this way we can learn the level of English mastered by the patient so that we know whether to send a questionnaire to be filled out at home, and can ask the patient what kind of communication he or she prefers to use. If the office does not have a TDD, it is possible to use a relay service to get the same information.
Except for the rare cases in which patients say that their lipreading (speech reading) and English are fluent, it is necessary to have an experienced interpreter present during the vision examination. Until now, the patient has usually arranged for interpreters by himself. Patients usually come to know local interpreters well and make appropriate choices for their medical examinations. However, it is better if the hospital trains a few interpreters to function in collaboration with its physicians and other personnel in order to improve the quality of communication.
If the hospital or clinic has no previous experience with interpreter services, the local interpreter referral service can help find interpreters who might be interested in receiving specialized training in medical interpreting. In smaller communities where there are no referral services, a registry of interpreters for the deaf can give the names of interpreters available in a given area. These organizations also give information on which interpreters are certified and thus are likely to be able to perform well as medical interpreters. An effective way of identifying good interpreters is to be in contact with the local deaf community grapevine.
Since taking a case history is time-consuming, as much information as possible should be collected beforehand. This includes gathering copies of old medical documents and the use of questionnaires sent to the patient's home or answered at the hospital before the examination. However, we must remember that English may be very difficult for many deaf patients and, while some questions are answered correctly, many will be misunderstood. All questionnaires should recommend the use of an interpreter, if needed, when answering the questions. In the future it might be possible to have video materials covering most of the basic questions related to the medical examinations.
The use of questionnaires imposes a new problem. Some patients will be able to respond to written questionnaires without the help of an interpreter in the usual waiting area. However, for those patients who require an interpreter, the waiting room is not an appropriate place to gather information. Signed information is visible at a distance and therefore the privacy of the patient is violated. A screen may be sufficient to solve this problem if a separate room is not available.
Even if the patient and the interpreter have discussed most of the questions before the examination, more time is needed than when examining a hearing patient because the interpretation requires extra time. Guiding the patient from one place to another may take more time, and in all new cases we have to be prepared for a variety of communication problems. When we learn to know each deafblind patient better, the time needed for an appointment can be individually planned.
When I see a deafblind patient for the first time, I set aside 1 to 1 1/2 hours. For patients who have recently been found in an institution and whose communication is not at all known, we may plan to use one whole morning. In this way I can spend some time with the patient, interpreter and rehabilitation counsellor, and then leave them to discover the best mode of communicating with the patient. Later, I can return to help analyze the observations, and then repeat this process several times. Sometimes we use this same technique with patients whose understanding of concepts related to eyes and visual impairment is very limited, so that there is need for special education before we can discuss the patient's problem. Thus, one single visit may take as many as four hours, although only a part of that time is spent with the patient.
In order to get copies of old charts we need a consent form from the patient. Usually, this consent form is reasonably easy to understand. When a patient comes to the hospital or to a private clinic and we need consent for any special examination or procedure, enough time has to be allocated for the interpretation and discussion of the contents of the consent form. Otherwise it cannot be considered an informed consent. In some cases it has taken as many as five visits to my office before a deaf patient has been able to sign a consent form for a cataract extraction. It can require all of these visits before the patient understands the nature of the operation and the different options available. We can seldom give written information as homework because written language does not convey enough information to the patient. Often an experienced nurse, working together with the interpreter, can save much of the doctor's time.
Some may ask why not make the decision for the patient if the physician knows that the patient will benefit from a certain procedure, such as a cataract extraction. This is a philosophical question, important in the care of all patients with communication handicaps. Only if the patient is unable to understand the nature of the procedure because of a mental handicap does the physician have the right to make the decision, after consultation with the legal guardian. However, if the patient does not have the mental capacity needed for full understanding, we are dealing with a learning situation and are obliged to teach and inform the patient so that he can make the decision himself.