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Practice Development | Sept/Oct '17

The Psychology of Choice Paralysis

Surgical and IOL options have increased significantly within the refractive and cataract spaces even in the past year. The approval of SMILE (Carl Zeiss Meditec) for myopia adds a third option to LASIK and PRK, and extended depth of focus IOLs and newer toric multifocals allow cataract and refractive lens exchange patients more options for a personalized plan.

At my practice, we mainly use eight different kinds of IOLs. Two of these can be yellow or clear; two can be aimed at distance, intermediate, or near; and four can target distance or intermediate. For two eyes, that equates to more than 40 combinations. From there, will it be laser or manual cataract surgery? Will we utilize a toric IOL or arcuate incisions? Will intraoperative aberrometry be used? We have all these options to offer patients, but that is not always a positive thing.


The psychology literature shows that the more choices a person has, the less likely he or she is to make any decision. One study was conducted in a grocery store with a display of gourmet jams. On some days, the display featured six varieties available for purchase. On other days, 24 varieties were available, and the larger display generated more interest. However, the study showed that, when it came time to make a purchase, shoppers who saw the larger display were one-tenth as likely to make a purchase as the shoppers who saw the smaller display. Offering more options resulted in dramatically fewer people making any purchase!

Another study looked at employer-sponsored retirement plans. When employees had more choices, fewer of them enrolled at all. So much for the benefits of personalization!

Even worse, having more choices actually reduces satisfaction for the same choice, because there are both real and perceived increased opportunity costs. If you leave the grocery store and are told at checkout you win $50 for being the thousandth customer, you’d be excited. But what if, as the thousandth customer, you could either take the $50 or whatever was behind door #1? If you took the $50, it is the same good outcome, but you might always wonder what was behind that door.


To patients, all options are mysteries. They do not know what a diffractive, apodized, toric multifocal IOL is and why they may or may not benefit from its use. Our goal is to eliminate the thought, “What if I had chosen something else?”

The first tool to reduce choice paralysis is to simplify patient counseling. For cataracts, instead of 40 lens options, we discuss the visual outcome desired: (1) no glasses most of the time through a broad range of vision, (2) no glasses most of the time at distance vision, or (3) glasses all the time for best vision. With refractive surgery, we achieve simplicity by making our LASIK, PRK, and SMILE cost the same for patients so that it is easier to maintain trust when we recommend the best procedure for their eyes.

The second tool is effective communication about the status of the patient’s eyes and lifestyle preferences. Effective communication establishes valuable trust and helps patients understand that certain lens options aren’t good choices because they may have an irregular cornea or an epiretinal membrane or need to drive or fly planes at night.


As technology progresses rapidly and options multiply, don’t keep adding lines to the “menu.” Keep refining your practice’s communication to remain patient-friendly.

Bennett Walton, MD, MBA
Bennett Walton, MD, MBA
Jonathan D. Solomon, MD | Section Editor
Jonathan D. Solomon, MD | Section Editor