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Cover Focus | Nov/Dec '21

Lessons in Dissatisfaction

Valuable conclusions can be drawn from challenging encounters.

The number-one lesson I have learned from a surgical patient occurred during my fellowship year, when I saw a middle-aged woman with severe glaucoma that resulted in small central islands of vision bilaterally. Her initial consultation revealed that each eye had a visual acuity of 20/40 and IOP ranging from 32 to 34 mm Hg on multiple medications. The patient had enlarged cup-to-disc ratios in both eyes, and ancillary testing made it clear that filtration surgery would be necessary to prevent disease progression.

Within a few weeks, she underwent successful trabeculectomy with the placement of an Ex-Press Glaucoma Filtration Device (Alcon) and adjunctive mitomycin C in both eyes. Despite well-controlled postoperative IOPs, the patient was frustrated that her vision had not improved. It was then that I realized that our goals of intervention and definitions of success had been misaligned.

I loaded her visual field test results onto the monitor that she could see from her exam chair and tried to find the best words to explain her condition—after we had already intervened. At this point, I knew that a direct delivery of facts with empathy was the best path forward. I patiently reviewed her exam findings and test results with her and paused intermittently to assess if she was grasping the critical nature of her disease. I could sense the mood in the room shift as she recognized that total blindness had been a very real possibility without immediate surgery. She began to cry.

Over the next couple of weeks, she was very understanding when we explained that we needed to lyse sutures to optimize her pressures. She also became more verbally engaged and started to participate actively in her own care. Our communication improved tremendously.

Ultimately, this experience taught me the importance of a patient yet persistent approach to evaluating and communicating with patients who may not understand the severe nature of their disease. It also taught me that, no matter how busy clinic may be, some encounters will simply require more time than others (especially to set proper expectations before any kind of intervention). Navigating this road while maintaining a sense of calm is the challenge—but also the joy—of clinical care.

Finny T. John, MD
  • Cataract and glaucoma surgeon, Vision Surgery Consultants, Wichita, Kansas
  • finnytjohn@gmail.com
  • Financial disclosure: None