EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/115557
September 2011 EW CATARACT 61 The art of advanced technology IOLs Observations versus complaints: Making a "c/o" error by Richard Tipperman, M.D. H ow many people in the world can do both a craniotomy and a continuous curvilinear capsulotomy? Well, Rich Tipperman, M.D., did a neurosurgery residency before switching to ophthalmology and becoming one of the best and busiest cataract surgeons at Wills Eye Institute, Philadelphia. Despite this powerful pedigree, Rich is one of the most humble and unassuming physicians that I have ever shared the podium with—something I've had the pleasure of doing many times. For refractive cataract surgeons, our surgical expertise and technical understanding of IOL design alone do not assure patient satisfaction. Instead, the need to properly evaluate and counsel refractive IOL patients has made effective communication more important than ever. Rich is one of my favorite speakers on this subject, and I've personally adopted many of his ideas and suggestions. He has such wonderful insights into how patients think that I sometimes wonder if his first career was in psychology rather than neurosurgery. Perhaps all of that time he spent dissecting patients' brains taught Rich how to read their minds. When discussing refractive cataract surgery, we don't emphasize communication skills enough. I've therefore invited Rich to share his practical insights and pearls in a regular EyeWorld column, which debuts this month. David F. Chang, M.D., chief medical editor Richard Tipperman, M.D. "Knowing is not enough; we must apply. Willing is not enough; we must do." –Johann Wolfgang von Goethe The application of medical sciences in a clinical setting can be a challenge. Ophthalmologists providing direct patient care must bridge the gaps between basic science, academic research, industry innovation, and patient education. It is hard to summarize this better than Goethe did in the above quote. The challenge for clinicians, especially with regard to advanced technology, is to take all of the basic science and clinical knowledge and be able to apply this to help patients. At the core of this is the ability to relate to and help a fellow human being. This column is dedicated and devoted to clinical ophthalmologists all over the world who are facing these challenges every day. I magine the following scenario: You perform flawless cataract surgery on a patient with a 4+ dense brunescent lens, shallow anterior chamber, and pseudoexfoliation. On the first post-op day the eye looks great with minimal post-op changes and the uncorrected visual acuity is 20/30. You tell the patient he looks and is doing great, and he responds that his vision is blurry. The patient points to the operative eye and says, "The eye feels scratchy." The first thing most ophthalmologists think is, "I can't believe he is complaining. Does he know how difficult and complex the surgery was and how well he is doing? What is wrong with this person?" Many surgeons will develop a jaded view of the patient's personality and adopt a defensive posture, which can be detrimental to the entire physician-patient therapeutic relationship. In the above scenario, the physician has fallen into a common communication pitfall of confusing observations for complaints. Many of the comments that patients share with us in the post-op period are statements of symptoms they are observing; they do not know whether these symptoms are normal or not and are seeking reassurance. Physicians however can interpret these comments as "complaints" and react in a defensive posture. To some degree this is inherent in physicians' training and culture. It is further biased by a common notation many learned in medical school and taught to our staff—this is the "c/o" error. Patients' subjective comments are often preceded by the abbreviation "c/o" (complains of) whether or not their statement was a true complaint or not. Ophthalmic surgeons and their staff deal with postop patients day in and day out and have a detailed and comprehensive understanding of what is normal and what is not normal; after a while staff and physicians can forget that this knowledge is neither common nor intuitive. This is certainly the case for our patients undergoing cataract surgery. They have no a priori experience with the surgical procedure and no frame of reference as to what they should expect. As such they will share with their providers many of the symptoms they are observing (e.g., "my vision is blurry," "it's tearing," "it's scratchy"). These are NOT complaints but merely symptoms they are experiencing—since they have no frame of reference to determine whether they are normal or not, they report them to the physician and staff seeking reassurance. If the ophthalmologist or staff reacts to and treats these observations and comments as complaints, this can lead to an insidious breakdown in the physician/patient relationship. The issue of "observations versus complaints" is especially relevant in patients who have received an advanced technology IOL. For many reasons, physicians and staff may be "overly sensitive" with regard to these patients and interpret statements or observations made by these patients as complaints. If a pa- tient with a presbyopia-correcting IOL were to make any of the following statements, how do you think you would interpret them? Statements include: "My eye feels scratchy," "Sometimes it's hard to read," "I have to wear glasses sometimes," and "I see light streaks at night." It is very likely that every one of these statements would be interpreted as a "complaint," but in many cases the patients are just seeking reassurance of a symptom they are observing. Even if any of these statements are a "true complaint," reassuring patients that the symptom they are having is "normal" and can be addressed with different interventions helps strengthen the physician patient relationship. For example, saying "I understand, Mr. Smith, you do need to wear glasses for some tasks occasionally—remember we discussed prior to surgery you might wear glasses sometimes? But we do have a lot to work with. It sounds like you are functioning for many tasks without correction, and if we address your surface dryness (or residual refractive error, etc.), I think we can get things even better for you." Once you are aware of the dichotomy of "observations versus complaints" it can change your perspective not only in the exam lane but in all aspects of your life. Statements by friends, colleagues, or family members that might have been interpreted as a "complaint" can now be recognized as an observation. When someone is "complaining," it sets up an antagonistic relationship where two people are on opposite sides of the problem. When someone makes an observation that you respond to then you are both "on the same side" of the problem and you are helping the person. This approach allows you to listen and look at the world in a different way. Ultimately this understanding may change your whole perspective on how you interact with others. This can improve your ability to understand and help others and also make your life easier. EW Editors' note: Dr. Tipperman has no financial interests related to this article. Contact information Tipperman: rtipperman@mindspring.com