Eyeworld

December 2017 • Ophthalmology Business 17 Whether it's a vision- threatening disease or a physician's error, how you deliver bad news to patients can make a difference P roviding compassion- ate care of the highest possible quality is what Paul Lee, MD, F. Bruce Fralick pro- fessor, chair of ophthalmology and visual sciences, and director, Kellogg Eye Center, University of Michigan, Ann Arbor, said all physicians aspire to do. One aspect of that, however unfortunate, requires physicians at one point or another to deliver bad news to a patient. For ophthalmologists, this can range from a cataract surgery not reaching its desired refractive out- come to irreversible, blinding retinal diseases to cancerous tumors that could have an impact beyond the patient's eyes. "Being able to communicate both good and bad news to our patients, and if they wish, their loved ones, is an important aspect of taking care of patients," Dr. Lee said. Appropriate communications are part of the National Academies of Sciences, Engineering, and Medi- cine's definition of diagnostic accu- racy, Dr. Lee pointed out. The Health and Medicine Division (previously the Institute of Medicine) defines diagnostic error as the "failure to a) establish an accurate and timely explanation of the patient's health problem(s) or b) communicate that explanation to the patient." 1 "It's not just being able to make the right technical diagnosis but be- ing able to communicate that to the patient," he said. Beyond how the news directly impacts the patient, how these situ- ations are handled by the physician and perceived by the patient can have implications for the physician and practice as a whole. "Patients' word of mouth refer- rals and their willingness to come back are heavily impacted by their perception of how well their physi- cian communicates. It's important for practice-building and retaining patients to have good communica- tion with patients," Dr. Lee said. This could also have legal impli- cations. "Compassion is the heart of a patient-physician relationship," said Jeffrey Maehara, MD, Maehara Eye Surgeons, Honolulu. "Bad news in the ophthalmologist's office can be devastating, and the artful delivery of bad news can prove your compas- sion and ensure patient comfort with your continued care. It is critically important that patients feel secure with the fact that the physician is truly here to support them in every way through this period. Maintain- ing patient rapport through these times is also an excellent way to keep you out of court if legal action is a possibility." Discussing negative outcomes Dr. Maehara said he does not think physicians in general are directly trained enough to break bad news to patients, nor are they "innately gifted at gentle delivery of such news." In a survey of 54 residents and attendings in the Department of Surgery at Baylor University Medical Center, Dallas, which was conduct- ed to determine if a didactic pro- gram was needed to enhance these communication skills, 90% said they think being able to deliver bad news to patients is an important skill for a physician to have, but only 40% said they felt trained enough to do so effectively. 2 "Experience and personal con- nection to patients may be responsi- ble for some of the disparity in skills we see in this area," Dr. Maehara said, adding that ophthalmologists in certain subspecialties, such as retina, might have more experience dealing with situations like loss of vision. Learning how to communicate bad news, and communicate effec- tively in general, is being incorporat- ed into medical school training, but a lot of this learning is picked up from mentors and role models. "There's that direct observational ability to do things in addition to classwork that's going on in medical schools around the country today," Dr. Lee said. Observing patients for how they prefer to receive information is important as well. Dr. Lee said one needs to recall previous communica- tions with the patient, picking up on clues as to what his or her preferred communication style may be. One should also act in accordance with your relationship to that patient. You may act on a more familiar level, for example, with a patient you've been treating for years compared to a patient you've only seen a couple of times. "Certain people like things presented certain ways," Dr. Lee said. "There are some patients who love to have a detailed discussion about the various options they have, and other patients who when I am having an in-depth discussion of the options got more and more concerned. Part of that is to get a sense of how pa- tients would like to get information." How do you learn this about a patient? "A big piece when you first meet folks is to listen to what they have to say after an open-ended question and not interrupt them," Dr. Lee said. "You'll get a sense of how patients like to talk, and doing some reflective listening is helpful so patients know you've heard what they're trying to communicate. Have appropriate body language or posture so pa- tients know you're paying attention. That's particularly important for new patients in the world of electronic health records, because so many electronic health records are set up so that the doctor may not be looking at the patient when they're putting information into the record. "If you have a new patient and you're typing in information as they speak but you're not looking at them, patients don't feel that you're paying as much attention as they'd like." continued on page 18

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