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Cover Focus | July/Aug '18

Red Flags

An overreaction to minor inconveniences, mistreatment of the practice staff, an unwaveringly cold disposition—the red flags. As health care providers, what we want most is to help people, to improve their vision and hopefully their quality of life. However, although mostly few and far between, there are occasions when we must say no to patients who seek care.

Despite our hyper-focus on the eyes, we ophthalmologists are, in essence, treating the entire patient. This, in turn, makes us involved in the patient’s total wellbeing. And sometimes that means we must screen out patients not for ophthalmic reasons but for psychosocial ones.

Here to help us dive into this topic is Parag A. Majmudar, MD. With substantial experience performing refractive surgery, Dr. Majmudar is tuned into the process of identifying patients who may be predisposed to dissatisfaction. He weighs in on the subtle cues he looks for and the approach he takes when having to dismiss a patient. —Gary Wörtz, MD

Gary Wörtz, MD: Parag, in a recent email exchange, you described a patient encounter that struck a nerve with me. The scenario involved a patient whom you chose not to treat, not for ophthalmic reasons but due to other concerns. As a preamble to that, why don’t you give us some background on your practice, and then we can dive into the story about this specific patient.

Parag A. Majmudar, MD: I’ve been practicing ophthalmology for 20 years, so I can easily say that I’m on the back nine of my career. With that definitely comes wisdom and a keen awareness of when things just don’t add up.

When I started practicing in 1998, the LASIK boom was in full swing. We ophthalmologists felt that we were invincible and could treat any patient who walked through the door. Ultimately, we learned more about corneal ectasia, and we devised a systematic approach to LASIK screening and gained access to the necessary tools. Now we know that we do not need to (and should not) perform LASIK on every patient who seeks it.

A valuable lesson, especially for younger ophthalmologists, is that you do not need to operate on every patient who presents for surgery. I think we all feel this internal pressure to make every patient who comes through our door extremely happy. However, it takes a bit of wisdom to realize that, in some cases, not operating may be the best way to make a patient truly happy, as surgery might not always be in the best interest of the patient.

As an example, there was one patient I saw a few months ago. She was in her early 50s and had come in for a LASIK evaluation. Most of the time, I think I’m a fairly personable guy; however, what initially struck me was that, as I walked in and introduced myself, she made very little eye contact with me. That was an initial red flag that something did not seem right and that maybe she was upset about something.

I looked a little further and found that she had actually previously been to our office for a visit, yet on that visit, she had left before seeing me. When I questioned her about that, I asked, “What happened that day? Was there an issue that we can improve upon?” From her response, I got the impression that she felt that we had done too much testing, and she grew anxious, felt like the visit wasn’t worth her time, and left.

From an ophthalmic standpoint, I thought she was a good LASIK candidate. She had moderately high myopia of -5.00 or -6.00 D and potentially could have had a good outcome with corneal-based refractive surgery. However, after I had a chance to open up with her a bit, I started to sense that maybe she was dealing with more issues than her ocular concerns.

Much has been discussed about the psychosocial factors involved in LASIK satisfaction. Various studies have shown associations between poor outcomes and depression and suicide in patients affected by these psychosocial factors. When I evaluated this patient’s past medical history, I saw she was taking a number of psychotropic medications. Her history, coupled with the fact that she seemed unable to handle what most would probably consider minor inconveniences in a doctor’s office, made me concerned about how she would respond to a possible less-than-ideal surgical outcome.

I asked myself, “What would I have done 20 years ago?” Given her physical candidacy, I would have proceeded with LASIK, and the patient might have done well. But, we certainly all have seen situations where patients have done relatively well from a visual standpoint but then complain of intractable dry eye, glare or halos, or some other emotional or psychosocial outcome that affects their satisfaction. So, I thought not only about myself and the prospect of having to see an unhappy patient for the next however many years, but also about the patient. I did not want her to unnecessarily undergo a procedure that might make her less happy than she was wearing glasses or contact lenses.

Most of us, especially in the early part of our careers, are so focused on the physical examination and outcomes that we sometimes overlook the relationship with the patient’s psychosocial function. It’s a big hurdle to overcome.

Dr. Wörtz: Patients are more than an eyeball, and once we operate on them, we are connected to them for a while, if not, in some ways, indefinitely. I think we have all gotten the sense that sometimes what patients are seeking in the outcome from surgery is not just improved vision; they’re potentially seeking happiness and, in some ways, thinking that surgery is going to make them happy. However, when their regular-life problems still exist postoperatively, they feel a sense of failure because, despite their expense trying yet another thing, it hasn’t delivered on the goods.

Dr. Majmudar: I agree completely. I think you hit the nail on the head in terms of the happiness factor. This is a common occurrence in the plastic surgery world, where patients are altering their bodies in hopes it will be a surrogate for happiness. With eye surgery, that is probably partly the situation as well. When there is something that is not quite up to the patient’s expectations, that, to him or her, equals unhappiness and creates the misconception that the procedure failed. The other issue specifically as it relates to vision is that it is obviously such a critical component of our lives, and if something affects our ability to work or perform daily tasks in some way, that can lead to psychological distress. I think that surgeons have to make a concerted effort to screen for these intangible issues. It is a great lesson for all ophthalmologists, especially those just starting out in practice.

Not all successful patient encounters hinge on a perfect surgical outcome—hence, the concept of 20/happy. Instead, much of our patients’ satisfaction hinges on a great physician-patient relationship and a level of trust. And sometimes you can’t get that in the first visit. Obviously, I didn't feel that there was enough of a bond with this patient on her first visit with me to recommend surgery at that time. If I felt like there was potential for a future procedure, I might have told the patient to come back for a follow-up examination. However, I did not feel that there was any way for me to make this patient happy based on her emotional situation at the time. Plus, with the previous episode where she became upset by the amount of testing that was being performed, I didn't feel like there was that necessary level of trust. When outcomes are great, and the patient is “happy,” we might be able to get away with not having the highest level of trust; however, if that outcome is slightly less than expected or if patients are relying on the procedure as a surrogate for their happiness, that can set into motion a complex series of events.

It’s certainly an art form to get that initial read of what the patient is expecting. Some red flags that may indicate unreasonable expectations include if the patient has been to multiple consultations, has a very type-A personality, is extremely nervous, fails to make eye contact, or seems agitated with minor little inconveniences. If a patient says, “I want to see 20/20 all the time,” that might not be a realistic option, and I think we’re all comfortable communicating that. The problem occurs when we think we can deliver everything the patient wants, yet there is still something that is not quite right. That’s the difficult part.

Preventing Patient Unhappiness

Keith Walter, MD, shares his method for identifying patients whose anatomies, pathologies, or personalities may prevent them from being entirely satisfied with cataract surgery results.

Dr. Wörtz: At our office, we have realized that sometimes patients treat the doctor very differently than they treat the front-office staff and the technicians. We’ve had conversations with our entire office to say, “We collectively have to own this potential problem.” As doctors, we see only a snippet of the visit. Sometimes patients, because of our position, may defer and be a little nicer to us. But, as a leader in an office, we have to protect our staff.

If someone is rude to any member of my staff, that red flag goes up. Our technicians will tell us if a patient has been demanding or rude, or if he or she has said anything off-color. I have had conversations with patients who would potentially be great candidates for multifocal IOLs, cataract surgery, LASIK, or refractive lens exchange, but their treatment of my staff gives me another insight into their demands and expectations.

Dr. Majmudar: Your point is very valid. There must be mutual respect if we are going to develop a relationship and try to help the patient. And it’s important to be on the side of your staff. Having that infrastructure where you can be warned before seeing the patient or maybe soon after, where the front desk flags the patient’s visit, is incredibly helpful. It is great to tell your staff, “We are on your side. We are all in this together. We want to make the patient experience great, but if there are certain things that are preventing that on the patient side, please let us know because that lets us understand how the patient deals with seemingly minor issues. If the patient is not able to deal with those minor issues, we’re potentially going to have a problem if there are minor issues following surgery.”

I’ve always said, even in my early career, I don’t need to make a billion dollars and operate on every single patient who walks through the door. I want to have happy patients, and I want to have patients whom we can do good for. If I don’t think we can do good for them, whether from a physical standpoint or from a more intangible psychosocial standpoint, then we need to nip that in the bud and tell the patients somehow.

Now, how do you that? My style is typically to underpromise and overdeliver. We downplay the potential benefits in terms of visual acuity and independence from glasses. If patients still have issues, you can gently communicate why the procedure will not be successful for them and say, "Mrs. Jones, I know you want to see for distance and reading and also be able to see sheet music 24 inches away, but we don't have a procedure that can do that at this time. Maybe we ought to revisit this." Or, I might try to communicate to the patient that they might not be an ideal candidate for a given procedure by saying, "You know, your cornea is a little bit on the thin side” or, “Your ocular surface may give us some problems." There is likely a way to gently inform the patient that maybe this is not the ideal situation in terms of what we can deliver.

I would almost never tell the patient that I don’t think he or she can handle surgery from a psychosocial standpoint. For the particular patient described above, there had been some discussion about her being in her early 50s, with low to moderate myopia, and she had indicated that she wanted to maintain near vision for some tasks. So, I told her, “LASIK may not be the best solution for you in terms of being able to deliver vision for distance as well as for some more near vision tasks. Maybe we ought to wait a year or 2 and let things stabilize, and then there may be more options in the refractive lens exchange arena that we can explore. There are always new lens implants coming out, and there may be potential for one procedure to accomplish multiple goals and tasks.” That is how I approached it with this patient, and I don’t think she interpreted that as condescending or an implication that I didn’t want to treat her.

Now, again, if the patient has been rude to the staff or threatens violence, those are patients with whom we may need to take a firmer approach by saying, “I don’t believe that we are the right practice for you. I don’t believe that we can deliver on your expectations, and I think it would be in your best interest to find another doctor. I hope you find a doctor who might be able to take care of you.” This phrasing advocates for your staff as well as the patient.

Dr. Wörtz: Excellent points. I think that the LASIK practices that have been dealing with these patients longer may have an advantage in the refractive cataract arena, as they likely already to have radar out for these more demanding patients. For people who are just dabbling in refractive cataract surgery, these patients can show up and really throw a wrench in the system, especially for a practice that is used to doing bread-and-butter general ophthalmology.

Dr. Majmudar: I agree. For those just starting out in practice and those implementing a new technology for the first time, I would recommend going slow and finding the patients who are going to be your homeruns. Start with the low-hanging fruit to not only hone your skills on the surgical side but also to gain experience analyzing patients and understanding what will make them happy.

We are not necessarily in the business of making patients 20/20 or 20/15. We are in the business of making patients happy in terms of how they perceive their vision helping them throughout their lives.

It has been a great blessing to be involved in refractive, corneal, and cataract surgery for the past 20 years. But with that comes a certain percentage of cases in which we must take a step back, evaluate the big picture, and ask ourselves, "Are we doing this to make us happy, or are we doing this to make the patient happy, and can we successfully do that?" Asking these questions is a great first step toward achieving our collective goal of patient wellness.

Parag A. Majmudar, MD
  • Associate Professor, Cornea Service, Rush University Medical Center, Chicago, Illinois
  • President and Chief Medical Officer, Chicago Cornea Consultants
  • pamajmudar@chicagocornea.com
  • Financial disclosure: None
Gary Wörtz, MD
  • Private practice, Commonwealth Eye Surgery, Lexington, Kentucky
  • Founder and Chief Medical Officer, Omega Ophthalmics, Lexington, Kentucky
  • Chief Medical Editor, MillennialEYE
  • garywortzmd@gmail.com
  • Financial disclosure: None