Perhaps the most important element to instructing patients and answering their questions effectively is primarily to consider yourself to be a teacher and fundamentally interested in education in the broadest sense of the word. This does not mean “filling up” patients with so-called facts or pieces of medical information. Rather, it literally means “leading forth.” The goal is to help the individual control his or her life in a way that will most likely lead to what that particular patient wants to achieve.

TIP NO. 1. BELIEVE EVERYTHING THE PATIENT SAYS
The words may be inappropriate, or even wrong, but underneath them will be a fundamental truth that the patient is trying to convey. It is your responsibility as a physician to translate those words so that you can understand that message. Moreover, you need to respond to the patient in ways that address that core issue with all the aspects of successful communication (body language, touching, speaking) that are meaningful to the patient.

TIP NO. 2. BE HONEST
It is possible to be completely honest without being cruel. Lying is almost always disrespectful and arrogant. A truth can be a lie, an intent to deceive. One of the most venal types of lying occurs when you fool yourself at the same time you are trying to fool the patient.

TIP NO. 3. SPEAK IN TERMS THE PATIENT CAN FULLY UNDERSTAND
Never use abbreviations or jargon. It is deeply disturbing for a patient to hear physicians speaking to each other about the patient's CRVO, his or her decreased MD, or the CME in the OD. Language like the pressure inside your eye or your eye pressure is far more accessible to patients than the term intraocular pressure. After you have said something to them, ask patients what they understood you to say. You will be shocked. You may think you were clear, but they heard something totally different from what you had in mind. Recognize these situations as opportunities to clarify your comments and to engage the patient more fully. You can come to understand the patient better and to have him or her understand you better so that, at the end of the conversation, he or she senses progress in being able to control his or her life.

A routine part of communicating meaningfully with patients is asking, “What does X mean to you?” and “What did you understand that I just said?”

TIP NO. 4. MAINTAIN HOPE
Try to avoid phrases such as Unfortunately … or I am sorry to tell you … . Just saying “unfortunately” will turn off the patient's ability to hear. State the facts in a way that they are understandable but phrased so as to maintain hope, because there is always hope. It is always possible to do something that will make the patient's life better.

TIP NO. 5. DO NOT CONFUSE THE PATIENT WITH HIS OR HER CONDITION
Do not say, “You are worse.” Rather say, “Your visual field has gotten worse in your right eye.”

TIP NO. 6. CONSIDER THE FUTURE
Think in terms of a video, not a snapshot. No treatment of any kind is justified unless you know that, without the treatment, the patient will experience a decrease in quality of life or develop some type of disability. If you cannot be sure of that, then there is no justification for starting the treatment, because every treatment causes problems. With that in mind, then, it is easy to say, “I am starting this drop because, without it, I believe that you are going to have a decrease in your ability to X (drive, read, play tennis, whatever is important to the patient).”

TIP NO. 7. USE YOUR WORDS AND GESTURES TO INSTRUCT PATIENTS
For example, if you have measured the IOP and say in a definitive, authoritative tone, “Your eye pressure is 15,” the patient will conclude that you really know that the pressure is 15. In actuality, of course, you do not know the IOP is 15 mm Hg. Furthermore, the pressure could easily have been 10 or 20 mm Hg 1 hour earlier or could be 10 or 30 mm Hg that evening. If instead you say something like, “As I measure your eye pressure just now, it is somewhere around 15,” you are instructing the patient in the difficulty of determining exactly what IOP a person has.

When you look at the second visual field and say, “Your visual field is worse. You had 4 dB of loss last time, and you have 8 this time,” the patient concludes that it is twice “as bad” as it was before. Of course, that is nonsense. A field change from 4 to 8 dB may not even be significant. Indicating to patients the softness of all these values is a critically important part of educating them. Everything you do or say teaches patients in some way.

TIP NO. 8. REMEMBER THAT YOUR FINAL COMMENTS WILL REMAIN WITH PATIENTS FOR MONTHS OR YEARS
Consider a patient who underwent a guarded filtration procedure 3 months ago. At this visit, you note that his or her visual acuity is one line worse. The eye exhibits mild bleb dysesthesia, but the IOP is around 12 mm Hg (which is where you wanted it). Your parting statement to the patient could be, “I am sorry your eye is so uncomfortable and that your vision is worse. Let's hope it clears up. It is important that I see you again in 6 months.” That patient will leave discouraged and will feel apprehensive for the entire 6 months.

Instead, your final remarks to this patient could be, “I am very pleased with the result of the surgery. I know that you now have mild irritation, but I also know that you can tolerate it. When your eye feels irritated, blink several times, and that will almost certainly make the eye feel better. Your sight is still excellent, and the likelihood is great that you will keep your vision for the rest of your life.” As you say these words, you hold the patient's hand and look him or her directly in the eye, because you are genuinely pleased. You add, “I am eager to see you again in 6 months. You are a real inspiration to me.”

George L. Spaeth, MD, is emeritus director of the William and Anna Goldberg Glaucoma Service and Research Laboratories at the Wills Eye Institute in Philadelphia. Dr. Spaeth may be reached at (215) 928-3960; gspaeth@willseye.org.