EyeWorld Asia-Pacific March 2021 Issue

NEWS & OPINION EWAP MAR C H 2021 53 by Liz Hillman Editorial Co-Director Having difficult conversations with patients Contact information Osher: RHOsher@cvphealth.com Parker: jack.parker@gmail.com This article originally appeared in the December 2020 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. D ifficult patient conversations— frequent or few and far between—are a part of any medical career, but preparing for those conversations is not generally part of medical training. “I don’t think that most residency programs spend much time devoted to patient communication,” said Robert Osher, MD. “I think that we’re more focused on academic knowledge and surgical technique and not as focused on the less scientific art of medicine. The art of medicine cannot be measured by a written examination; it is more about people skills.” Dr. Osher and Jack Parker, MD, teamed up to write a book on how to have some of these conversations—”What I Say: Conversations That Improve the Physician-Patient Relationship” (Slack Publishing)—with other ophthalmologists taking on specific chapters to share their insights. Before getting into how to handle some specific difficult conversations, Dr. Osher said there are some general principles. Communication is just as important as one’s surgical technique in the operating room or how well the slit lamp examination is performed, Dr. Osher said. He recalled the words of Lawton Smith MD, a neuro-ophthalmologist with whom Dr. Osher had a fellowship: “Every patient cannot be cured, but you can comfort everyone.” “He was the most compassionate ophthalmologist I have ever worked with. … That made a lifelong impression on me,” Dr. Osher said. One of Dr. Osher’s general principles is to really listen to the patient and be completely honest about what’s going on. Another is to show the patient that you really care, Dr. Osher continued. Eye contact and, pre- pandemic, a reassuring touch on the arm or shoulder are important. “I know it sounds like a cliché, but I treat the patient like my family. … I want to give the patient the most honest, caring, reassuring explanation and let them know that I’m on their team … that we’re in this together,” Dr. Osher said. Dr. Parker offered a few thoughts on what he thinks are some of the most difficult topics/ conversations to have with a cataract or refractive patient. “Conversations doctors are afraid of are the ones where you’ve done surgery, and whether or not it’s your fault, there was a problem,” Dr. Parker said. “Now you need to deliver unexpected bad news to someone.” This can be especially hard because cataract and refractive surgeries are often considered elective, relatively quick, and complications are generally rare. Dr. Parker’s general advice is to think about what you’re going to say ahead of it. This can alleviate fumbling for the right words when you and the patient might be upset, he said. “Think of what is the most empathetic, most understandable way to explain the problem,” he said. The following are a few specific difficult conversations and some thoughts on how to address them. Posterior tear or dropped nucleus In Dr. Parker’s and Dr. Osher’s book, David Chang, MD, wrote this chapter. According to Dr. Parker, the terminology he uses is calling the tear a “split.” Another point he makes is that you want to avoid assigning blame. Dr. Parker said assigning blame implies that something went wrong during surgery that could have transpired differently. “Rather than invite that hypothetical universe in which everything was fine, just describe the situation,” Dr. Parker said. Refractive surprise This chapter was written by Warren Hill, MD, Dr. Parker said. First, Dr. Parker said the chapter described talking about how IOLs come in steps, similar to shoe sizes. The problem is the exact size of your eye might not be the exact size of the lens, so you have to choose the closest size, up or down. “That inevitably leaves some refractive error in everyone,” Dr. Parker said. Ophthalmologists should also explain that the shape and curvature of the eye can influence the IOL decision, and errors in measurements can