I don’t know of anyone who went into optometry in order to sell frames, anti-reflection coatings, photochromics, or lens cleaners (products). In my optometry year group and most of those I taught in 20 years as a university-level teacher most of the people I met wanted to provide eye care; examine people’s eyes, work out what lens power they need, and send them on to another specialist if necessary (service). A small minority wanted to own a franchise practice in order to have a big house and a fancy car. That group would have gone into optometry in order to sell stuff.

I can’t remember when I first found out that as well as examining people’s eyes I was also expected to sell stuff. Probably around about year 6 in, when I moved out of hospital practice into independent practice. ‘Your conversion rate isn’t good enough’. I was told. I thought the practice owner said ‘conversation rate’ so I said if I speak any quicker people won’t understand me. I hadn’t heard of conversion rates before. I knew that it was the money from spectacle sales that ensured a practice’s prosperity but didn’t know that a 60-80% conversion rate was required to pay all the bills and salaries.

When I owned my own practice I always focused on doing the right thing for the patient and never on conversion rates. The practice continued but I never did have a big house or a fancy car.

I read about a study conducted in the US in 2003. Personality profiles of different types of health professionals were examined. Optometry students were more likely warm-hearted, responsible, and reserved personality types, highly agreeable in nature with low extraversion. People with this kind of personality trait are portrayed as being kind in excess and conflict-averse.

Put simply our patients are consumers of our outputs and our outputs can be separated into products and services.

Stress develops when a system attempts to be in two places at the same time. Optometrists with a typical optometrist personality become increasingly stressed the less egalitarian our outputs become and, as such, we can become uncomfortable or even guilty at the idea of selling and caring at the same time. Optometrists who are warm-hearted, responsible, and reserved personality types, will have a preference for providing egalitarian care. Egalitarian means believing in or based on the principle that all people are equal and deserve equal rights and opportunities. Deciding to recommend a product that means extra expense can become stressful for this type of optometrist. Some people will be willing to pay and others won’t. This means that people won’t be treated equally.

Do we provide information to patients about the product and put the decision in the patient’s hands, or rely on ourselves as experts to provide the best option based on our clinical knowledge and experience? Giving patients the option has become a reflex to pivot away from being accountable, selecting a product, and standing behind it. Some optometrists may think that by making clinical recommendations, such as an antireflection coating the patient will think they are up-selling. The warm-hearted, responsible, and reserved optometrist cringes at the idea of being accountable, on the chance that their recommendation will fail and possibly lead to conflict. With this anxiety over accountability, our duty to do no harm competes with our angst over managing a potential conflict.

But there is a false assumption that patients understand the nuances of clinical decision-making and of optical devices (and other products) as well as we do. Instead of making the best choice, patients may lose trust in you as their optometrist.

I gave up a role because I was expected to sell when there was no clinical benefit from the product I was told to sell. I was shamed into following recommendations that were counterintuitive and that led to conflict This led to stress because I was focused on clinical care (service and some product) while the higher-ups were focused only on the product. This led to me being unhappy and being unhappy is inefficient. This is an example of cognitive dissonance which is a mental conflict that occurs when a person’s beliefs don’t line up with their actions. It’s an uncomfortable state of mind.

I’m in a different role now where I can work with accountability and curiosity and without expectation, we can remove the dissonance and anxiety that has been growing on our side of the slit lamp. Recognize that the need to make a patient like us or our recommendations is irrelevant and self-generated.

I don’t focus on what the patient might be thinking but focus on providing the best eye care and some of this involves recommending product. I’d be wasting time and energy trying to work out the patient’s perceptions. So, if during history and symptoms, I discover that a driver is having problems with night glare I advise an antireflection coating. I focus on objective decision-making that is specific and hinges on my clinical experience and the patient’s clinical needs and wants. Asking the patient a question that leads to a solution becomes a collaborative process.

I am accountable and empathetic. I don’t linger on indecision and don’t outsource clinical decisions to my patients.