As I near the halfway point of my glaucoma fellowship, I find myself reminiscing about the lessons I have learned so far. My fellowship at the University of Alabama Birmingham has provided me with a diverse, high-volume training experience, and each faculty member has offered me unique learning opportunities (Figure).
Figure. Dr. Knox in the OR during fellowship at the University of Alabama Birmingham, where he is training under seven glaucoma specialists.
Our glaucoma department consists of seven glaucoma specialists, all of whom I consider mentors. Each of these specialists trained at different major academic institutions across the country, and, despite some inherent differences, they all excel in the crucial aspects of glaucoma management. This article provides an overview of what I have learned about the essential facets of glaucoma care, which include building patient trust, monitoring disease, advancing therapy, and managing complications, all of which intertwine during a glaucoma visit.
BUILDING PATIENT TRUST
Fellows are at a significant disadvantage in the realm of patient trust. It is often shortly after my introduction to a patient that I have to recommend surgical management. Upon hearing my recommendation, patients frequently start fidgeting in their chair, begging for the final recommendation to be made by the attending physician. Next, the attending steps in and spends a fraction of the time recommending the same surgical procedure to the patient—but this time, the patient’s demeanor is completely accepting. It is likely that anyone in training can appreciate this scenario.
Sometimes credentials alone are enough to establish patient trust. But often, patients require a relationship to develop over the course of many visits before they feel confident in your care. This is even truer when it comes to patients with glaucoma, as the disease is often asymptomatic and surgical treatment can carry significant risk. As glaucoma specialists, we must be aware of how patients’ values and characteristics may influence their compliance. If we can understand our patients better, they, in turn, will trust us more, which will lead to more effective treatment.
“Thirteen? My pressure was 12 last time. I promise I’m using my drops, doc.” Why do patients obsess over minimal fluctuations in IOP? They often attribute a single-point increase in pressure to their glaucoma worsening. Haven’t they learned about diurnal variation?
A great way to help patients better understand their disease is by showing them their testing. Allow the electronic health record to be a tool, rather than a barrier, in your discussion with the patient. The OCT color scale and visual field gray scale can serve as visual representations. Additionally, the progression analysis feature on the Spectralis (Heidelberg Engineering) provides a simple printout that may help patients better understand the end goal of their treatment. In asymptomatic disease, this can be an invaluable piece of validation. As a fellow, I use this tactic to build trust quickly during a patient encounter.
Because switching drop therapy is rather routine, I’ll skip right to the surgical discussions. The surgical pitch can dictate the entire postoperative period. There truly is no such thing as fully informed consent. No matter how detailed you are with the information you provide, patients often aren’t able to grasp the entire surgical concept.
The motto for glaucoma surgery should be under-sell and over-deliver. Surgery is performed for a reason, but it can be a tough concept for patients to grasp, especially because it frequently results in worse vision, at least temporarily. A wise attending of mine often says, “Glaucoma surgery is the back surgery of the eye.” Now that’s a medical analogy that people can understand. Setting expectations is important in surgical management and key to setting the tone for postoperative visits.
If you perform glaucoma surgery, you will encounter postoperative complications: hypotony, bleb leaks, endophthalmitis—oh my. Early in my fellowship, I realized perfection was not attainable. At first, nothing was more frustrating than my same-day postoperative trabeculectomy having an IOP measurement that was higher than at the preoperative visit.
Managing complications entails accepting the inevitable, readdressing patient expectations, and treating said complications with the appropriate medical or surgical means. Encountering a complication does not, however, warrant panic. All of my attendings remain stoic in such circumstances. Some of the most valuable lessons I have learned in fellowship have come in the wake of a complication.
When I was a resident pondering glaucoma fellowship, an upper-level resident told me that no one ever regrets doing a fellowship. Although this may not be absolute, it has held true in my case. The lessons I have learned over the past several months may be subject to change over the course of my career, but in the meantime I hope my perspective on these crucial aspects of glaucoma care provide useful takeaways for other trainees.