Having difficult conversations with patients
by Liz Hillman Editorial Co-Director
An unhappy patient or an unexpected postoperative outcome can lead to difficult conversations. Sooner or later, all ophthalmologists will encounter this challenge in their career. Current medical school and residency curriculum does not prepare us adequately for these situations. In this issue, the YES Connect column delves into this topic with two experts sharing how to properly navigate these difficult conversations.
—Soroosh Behshad, MD, MPH
YES Connect Co-Editor
Difficult patient conversations—frequent or few and far between—are a part of any medical career, but preparing for those conversations is not generally part of medical training.
“I don’t think that most residency programs spend much time devoted to patient communication,” said Robert Osher, MD. “I think that we’re more focused on academic knowledge and surgical technique and not as focused on the less scientific art of medicine. The art of medicine cannot be measured by a written examination; it is more about people skills.”
Dr. Osher and Jack Parker, MD, teamed up to write a book on how to have some of these conversations—”What I Say: Conversations That Improve the Physician-Patient Relationship” (Slack Publishing)—with other ophthalmologists taking on specific chapters to share their insights.
Before getting into how to handle some specific difficult conversations, Dr. Osher said there are some general principles. Communication is just as important as one’s surgical technique in the operating room or how well the slit lamp examination is performed, Dr. Osher said. He recalled the words of Lawton Smith MD, a neuro-ophthalmologist with whom Dr. Osher had a fellowship: “Every patient cannot be cured, but you can comfort everyone.”
“He was the most compassionate ophthalmologist I have ever worked with. … That made a lifelong impression on me,” Dr. Osher said.
One of Dr. Osher’s general principles is to really listen to the patient and be completely honest about what’s going on. Another is to show the patient that you really care, Dr. Osher continued. Eye contact and, pre-pandemic, a reassuring touch on the arm or shoulder are important.
“I know it sounds like a cliché, but I treat the patient like my family. … I want to give the patient the most honest, caring, reassuring explanation and let them know that I’m on their team … that we’re in this together,” Dr. Osher said.
Dr. Parker offered a few thoughts on what he thinks are some of the most difficult topics/conversations to have with a cataract or refractive patient.
“Conversations doctors are afraid of are the ones where you’ve done surgery, and whether or not it’s your fault, there was a problem,” Dr. Parker said. “Now you need to deliver unexpected bad news to someone.”
This can be especially hard because cataract and refractive surgeries are often considered elective, relatively quick, and complications are generally rare. Dr. Parker’s general advice is to think about what you’re going to say ahead of it. This can alleviate fumbling for the right words when you and the patient might be upset, he said.
“Think of what is the most empathetic, most understandable way to explain the problem,” he said.
The following are a few specific difficult conversations and some thoughts on how to address them.
Posterior tear or dropped nucleus
In Dr. Parker’s and Dr. Osher’s book, David Chang, MD, wrote this chapter. According to Dr. Parker, the terminology he uses is calling the tear a “split.” Another point he makes is that you want to avoid assigning blame. Dr. Parker said assigning blame implies that something went wrong during surgery that could have transpired differently.
“Rather than invite that hypothetical universe in which everything was fine, just describe the situation,” Dr. Parker said.
This chapter was written by Warren Hill, MD, Dr. Parker said. First, Dr. Parker said the chapter described talking about how IOLs come in steps, similar to shoe sizes. The problem is the exact size of your eye might not be the exact size of the lens, so you have to choose the closest size, up or down.
“That inevitably leaves some refractive error in everyone,” Dr. Parker said.
Ophthalmologists should also explain that the shape and curvature of the eye can influence the IOL decision, and errors in measurements can result in a refractive surprise.
In this situation, give the patient hope. These errors are usually rectified by a simple additional surgery, Dr. Parker said.
Dr. Osher discussed this situation in his interview with EyeWorld. He explains to the patient that IOLs “are made in steps, for example, +21, +22, and +23. You may need a +22.6 for perfect vision, which isn’t made. Therefore, we err up or down to the nearest available lens, which may leave a touch of nearsightedness, farsightedness, or astigmatism,” he said.
In addition, Dr. Osher explains to patients that everyone heals differently and how this can influence the outcome. “I always tell the patient that he or she may need a thin pair of glasses after surgery. It’s better to under promise and over deliver,” he said.
“I will finish by saying something reassuring … always try to end on a high note,” he said, such as, “I’m confident that you will be seeing much better after your surgery.”
“I always try to show each patient that I sincerely care and that I plan on doing my best,” Dr. Osher added.
Even if the surgery went perfectly and the outcome, by quantifiable measurements, was a success, patients can still be unhappy with the result.
Dr. Osher reiterated the importance of giving the patient time, reassurance, and an honest explanation. He likes to compare unaided vision in the operated eye to the other; if that isn’t impressive enough, he shows the patient the preoperative and postoperative lines on the Snellen vision chart for their comparison.
Leaving a patient without a lens
Dr. Parker thinks this is an important conversation to prepare for, especially for those early in their career. When the capsular bag is compromised, surgeons have three options: put the lens in the bag with a sometimes technically complicated fixation technique; use an AC IOL, which he said can have problems later; or leave the patient without a lens.
“Most surgeons don’t want to have to explain to the patient why they didn’t put a lens in … and instead put the worst lens in the worst location, and it ends up causing problems for the patient down the line,” Dr. Parker said.
Instead, he advised preparing for this type of conversation ahead of time so the patient can be referred to a doctor more experienced in performing the fixation techniques for IOLs in these situations.
The number one mistake Dr. Osher thinks doctors make when there is a complication is that they distance themselves from the patient.
“It should be the exact opposite,” Dr. Osher said.
It is the complicated patient who should receive personal calls to see how they’re doing, the one who should be offered genuine concern and reassurance.
“This is the patient you want to shower with attention. … The patient knows I really care. That goes a long way,” he said.
Some of these conversations can also be made easier if the preoperative discussion is handled differently.
“For example, if patients who have undergone previous refractive surgery are told ahead of time that they will probably need a thin pair of glasses following surgery, it becomes an expectation and not a complication,” Dr. Osher said.
About the physicians
Robert Osher, MD
Professor of Ophthalmology
University of Cincinnati
Medical Director Emeritus
Cincinnati Eye Institute