Eyeworld

EW NEWS & OPINION 20 May 2016 What's my line? Pearls for effective patient communication in your eye as I do more than 99% of the time. An opening in the back bag occurred during the surgery, which caused the gel called vitreous, which usually stays in the back of the eye, to come forward. This is a complication that must be handled in a very special way for the best outcome. I was able to deal with the complication, removing the gel from the front of the eye where it doesn't belong, and removing the cloudy lens as well." In the rare event there is dropped nucleus, I also explain: "Some of the cloudy material fell through the opening in the bag to the back of the eye, which cannot be safely removed with the cataract machine. This may require a second surgery by my retina specialist who has extra training and equipment to get your best outcome. I would like him (or her) to see you now so we can follow you closely together, giving you every chance for a perfect recovery despite this complication. "I was able to place the implant securely, and I still expect you to have an excellent result and recover your best vision. You might never have known there was a complica- tion if I didn't tell you, but I feel it is your right to know. The risk of the retina detaching or the pressure in the eye becoming high and need- ing treatment is slightly increased because of this complication. You may see some floaters, which will go away in time, but should never come back again, or I would want to know. We will follow you more closely and use eye drops for longer to help you recover completely. I want you to be especially aware of any change for the worse and tell us. I will be available to you anytime I can if you have any problems or questions. Otherwise I'll see you as scheduled." I also give these patients my cell phone number, which I write on my business card. I add, "I want you to have my personal number, which I hope you'll lose when you no longer need it. I want to be sure in the rare event you need to get ahold of me that it's easy. Any questions?" I always allow the patient and family to ask any questions then, of- ten saving time and frustration later. Physicians share advice on effectively communicating with patients P hysicians were asked, "How do you explain unplanned vitreous loss to patients?" This is how several responded. Communicating unplanned vitreous loss to patients W hat a challenge it is to tell patients that something didn't go quite right during surgery without increasing their fear or dissatisfaction. The focus here on vitreous loss provides a rich opportunity to learn some communication pearls that balance honesty with relation- ship preservation. Each of the following script examples has 2 phases: patient preparation, followed by post-surgical debriefing. Notice the pearl of anticipatory guidance at the front end. The ophthalmologists educate their patients (without alarming them) about possible surgical complications so that they have reality-based but generally positive expectations—consistent with surgical outcomes statistics as a whole—so that "forewarned is forearmed." In phase 2, notice how the ophthalmologists describe vitreous loss with honesty and in language that is clearly understandable to patients, and also provide information and opportu- nities that can empower and support the patient. For example, there is a continued positive expectation regarding the eventual outcome, and patients are invited to be part of the best possible recovery by playing their part in following postoperative recom- mendations (e.g., taking prescribed drops, refraining from rubbing the eyes, etc.). However, perhaps the most emotion- ally assuring measure communicated to patients after vitreous loss is that they are not alone in their recovery, as evidenced by providing them personal cell phone numbers and the genuine request that they call any time for any reason. It's no surprise that this polling of expert ophthalmologists has yielded communication pearls that combine technical wisdom with effective bedside manner. Craig Piso, PhD, What's my line? editor Lisa Arbisser, MD Adjunct associate professor, Moran Eye Center, University of Utah, Salt Lake City I say to patients: "I know you under- stand that you are not a widget, and I am not divine. Although cataract surgery is quick and slick the vast majority of the time, as you know from the consent form you signed, it is not always uncomplicated. "The cataract is like a cello- phane bag containing cloudy lens fibers that blur the light rather than allowing it to pass through, which is why you needed this surgery to clear your vision. Our goal is to open the front bag and remove that cloudy material, leaving the back bag, which is finer than plastic wrap, in- tact. This is where we place the new manmade lens, the implant, to focus light again on the back of your eye, the retina, which does the seeing." I show the patient a model of the eye while giving this explana- tion. "I use the most modern equipment available known as a phacoemulsification machine, which, in effect, works like a mi- croscopic jackhammer between 2 delicate membranes to break up and suck away the cloudy lens. Despite the best training, 30 years of experience, and caring attention, I was unable to achieve an intact bag continued on page 22 Mark Blecher, MD Co-director, cataract and primary eyecare, Wills Eye Hospital, Philadelphia Vitreous loss is an unintended event that has documented potential ad- verse effects. For me, that is the defi- nition of a complication. In decid- ing what you are going to say, you have an obligation to use language that the patient can understand, which will obviously differ from patient to patient. If your patient is a fellow ophthalmologist, your talk will differ from one you would have with someone without a medical background. In addition, while you want to convey the appropriate degree of seriousness, you should avoid creating fear and undue panic. "Ms. Smith, while I was remov- ing your cataract, I ran into some difficulty that required an extra step in your surgery to ensure the best results. When we remove the cata- ract, we are really only removing the inside of the cataract. We open the cataract up and remove the cloudy part and leave the clear outer shell to support the new implant. While doing this, there was a defect in the shell, and this allowed the jelly behind the cataract to come forward where it doesn't belong. In order for the new lens to be positioned prop- erly, and to have the best results, we needed to clean up the jelly that was where it wasn't supposed to be. We did this and put your new lens in place. At the end of surgery, every- thing looked as it was supposed to, and I anticipate a good recovery, although we will of course be watch- ing to make sure there aren't any further problems from this."

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