A Patient Yet Persistent Approach
By Finny T. John, MD
The number-one lesson I have learned from a surgical patient occurred during my fellowship year, when I saw a middle-aged woman with severe glaucoma that resulted in small central islands of vision bilaterally. Her initial consultation revealed that each eye had a visual acuity of 20/40 and IOP ranging from 32 to 34 mm Hg on multiple medications. The patient had enlarged cup-to-disc ratios in both eyes, and ancillary testing made it clear that filtration surgery would be necessary to prevent disease progression.
Within a few weeks, she underwent successful trabeculectomy with the placement of an Ex-Press Glaucoma Filtration Device (Alcon) and adjunctive mitomycin C in both eyes. Despite well-controlled postoperative IOPs, the patient was frustrated that her vision had not improved. It was then that I realized that our goals of intervention and definitions of success had been misaligned.
I loaded her visual field test results onto the monitor that she could see from her exam chair and tried to find the best words to explain her condition—after we had already intervened. At this point, I knew that a direct delivery of facts with empathy was the best path forward. I patiently reviewed her exam findings and test results with her and paused intermittently to assess if she was grasping the critical nature of her disease. I could sense the mood in the room shift as she recognized that total blindness had been a very real possibility without immediate surgery. She began to cry.
Over the next couple of weeks, she was very understanding when we explained that we needed to lyse sutures to optimize her pressures. She also became more verbally engaged and started to participate actively in her own care. Our communication improved tremendously.
Ultimately, this experience taught me the importance of a patient yet persistent approach to evaluating and communicating with patients who may may not understand the severe nature of their disease. It also taught me that, no matter how busy clinic may be, some encounters will simply require more time than others (especially to set proper expectations before any kind of intervention). Navigating this road while maintaining a sense of calm is the challenge—but also the joy—of clinical care.
A Lifelong Course of Trials and Triumphs
By Natasha Nayak Kolomeyer, MD
My patients have taught me a lot. Although most cases go well, complications occur. As my mentor often says, “The only way to avoid complications is to avoid surgery altogether.” Every glaucoma surgeon has dealt with suprachoroidal hemorrhages, choroidal effusions, bleb leaks, and clinical hypotony if they have performed enough cases. Patient dissatisfaction can accompany complications—but it doesn’t always. Following are a few key insights into patient satisfaction and dissatisfaction that I have gained over time.
No. 1: Satisfaction is relative. One of my patients underwent three procedures in 1 month; he experienced an IOP spike after cataract surgery that did not resolve with tube shunt implantation and eventually required cyclophotocoagulation. Although I had expected this patient to be dissatisfied and disappointed, I was surprised by his contentment. On the other hand, the mildest transient microhyphema (with 20/20 visual acuity) that resolved in less than 2 weeks caused another patient immense stress and dissatisfaction. Patient satisfaction is certainly relative.
No. 2: Transparency and understanding go a long way. I have learned to inform patients if something out of the ordinary happens and to be clear about why they may need to see me more frequently. The burden of frequent visits is real, regardless of the patient’s visual outcome. I remember an 88-year-old patient who had persistent shallow anterior chambers and choroidal effusions after tube shunt surgery. She brought in a different grandchild every time she saw me during her postoperative period; after we got past the initial discomfort, we eventually joked that I was glad she had at least 12 grandchildren to make use of. I was grateful for the opportunity to meet her whole family, although I would never have wished that experience upon her.
No. 3: Dissatisfaction is often temporary. One of my patients made it very clear that she was upset that I had shown a photo of my new baby to another patient but not to her. Overcoming her dissatisfaction was as uncomfortable as dealing with some of the challenging surgical and clinical situations mentioned earlier. I have learned, however, that it is sometimes necessary to deal with temporary discomfort in order to develop stronger relationships with patients. Typically, dissatisfaction stems from a misunderstanding or misalignment of expectations.
In most cases, glaucoma is a lifelong disease, and we have the pleasure and the challenge of accompanying patients through all of the trials and triumphs that occur along the way.
