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5 The VR Surgeon’s Relation to His Patient: Counseling |
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5.2The Patient Does Not Know Most of What Is so Obvious to the Surgeon
Once the surgeon makes the diagnosis, he must inform the patient (and, preferably, his family) about the following:7
•The eye’s normal anatomy and physiology. Without this, it is impossible to explain to the layperson what is wrong with the eyeball.
•The current condition, describing the pathology that requires a decision whether to treat it.8
•The options to choose from. Barring untreatable conditions, there are always at least two choices: do nothing (elegantly called observation or “watchful waiting”) or do something; typically, the “do something” is not a singular option but can be subdivided into several choices.
–Briefly, and as appropriate, each surgical procedure should be described.
–Presenting the options, the surgeon should try to provide numbers (percentages) for each:9 prognosis, intraoperative, and early and late postoperative complications.10
–Counseling is not about one particular tissue lesion only. For instance, if a patient who presents with a macular hole is found to also have a subluxated IOL, he needs to be asked about how much the IOL’s position interferes with his visual functions. If the patient considers it a major hindrance, the VR surgeon should offer repositioning or replacing the IOL during the PPV (see
Sect. 38.5.1).
Counseling is not restricted to a preoperative discussion; it may continue intraoperatively if the patient is awake (see Table 15.1) and certainly must continue postoperatively, from “the day after” to the very last follow-up visit.
7The information must be as short as possible but as detailed as needed so that the patient can have the final say in the decision-making process. Making the patient read and sign a sheet of paper called “informed consent” is insufficient, even if accompanied by a video explaining the operation for the patient’s condition. There is no substitute for personal interaction and explanation.
8For example, I usually describe an RD as a wallpaper, which has peeled off the wall and is now found in the room. To make it a wallpaper again – to allow the film of tissue, the retina, to work and not lose its function permanently – the wallpaper must be put back on the wall. If SB is performed, the wall and the wallpaper are joined again by pushing the wall in; in PPV the surgery is performed inside the room, pushing the wallpaper back onto the wall. However, the latter is a technical issue that I explain only if the patient asks about the surgical technique.
9In the case of an RD: a roughly 80–90% initial success rate. If PPV is performed, there are rare complications such as ECH or endophthalmitis, which occur in less than 1 in 1,000 operations; the main long-term issues are cataract in the phakic eye and re-RD in ~15% of the cases. An RD can occur early, due to a break, or several weeks later, due to PVR.
10Once the patient made his choice, he must be informed about the recognition of the complications.
5.4 Coaching vs Trying to Be Objective |
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5.3Communicating with the Patient
Counseling is not a monologue but a dialogue, even if the surgeon is the “primary speaker”; the patient is encouraged to ask questions and voice comments and concerns. While talking, the surgeon must read his patient’s face and tailor his message according to the patient’s facial expressions.
Q&A
QHow do you adapt your message or choose your words for that individual patient?
AKnowing the patient’s educational level and intelligence and whether the patient seems to have common sense is very helpful. The surgeon must also learn to decipher the direct (verbal: the way the patient phrases his questions) and indirect (metacommunication) feedback of how his message gets across. These signals of the latter include, among others, whether the patient’s face reflects understanding or being at a loss and whether the patient’s metacommunication is in agreement with his verbal message.
The surgeon should be able to read the patient’s metacommunication but must also know that most patients will read his own metacommunication. It is crucial for the surgeon not to show contradiction between his verbal message and facial expression, body language, and hand gestures. Even if pressed for time, he should not be caught looking at his watch while the patient talks.
5.4Coaching vs Trying to Be Objective
By diagnosing the disease, the surgeon knows what his own preferred management option would be. Figure 5.1 helps the surgeon navigate so as to avoid the trap of coaching, unequivocally influencing the patient to choose the surgeon’s preferred option.11
Pearl
The negative consequence of coaching may never surface; however, if something goes wrong, in today’s litigious environment, a lawsuit may follow. The patient’s lawyer will argue that had the patient not been told what the surgeon’s preferred treatment option is, he would have chosen something else, which surely would have been more successful.
11 Coaching may be done in a way that while all that is said is true and there is an apparent choice for the patient, in reality the selection of the words makes one option very suggestive.
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5 The VR Surgeon’s Relation to His Patient: Counseling |
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The way the surgeon phrases his message suggests that one option is so much superior to all others that this leaves virtually no reasonable alternative
The diagnosis is made
The surgeon knows which treatment option he wants the patient to prefer
Counseling
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implications of that option are; if the |
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risks, and the surgeon is now |
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comfortable with the choice, he should |
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proceed with it. If still uncomfortable, |
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he should refer the patient |
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The way the surgeon phrases his message leaves other, reasonable alternatives open; by understanding the rationale, risks, and benefits for each option, however, the patient understands the superiority of the option the surgeon preferred in the first place
Fig. 5.1 Influencing the patient’s choice of treatment. With the “coaching” option the surgeon, directly or indirectly, tells the patient which option he should choose. If one treatment option is clearly superior to all others (such as vitrectomy, as opposed to intravitreal antibiotics alone for traumatic endophthalmitis [see Sect. 45.3]), this is perfectly fine. In many cases, however, there are several options available, and with each the surgeon can reasonably argue in favor of or against. In such cases he should try to remain as objective as possible and describe the options so that the patient can make the choice. If the patient chooses an option that the surgeon truly feels uncomfortable with, he should re-explain the options and clearly state the disadvantages of that option. If the patient does not change his mind and the surgeon remains uncomfortable with the choice, he should refer the patient, rather than do something against his own conviction. The thick arrows represent the likely and the thin arrows the unlikely chain of events
Counseling is done correctly when the surgeon informs his patient in an objective manner, presenting options without making the patient feel that the surgeon prefers one option over the other/s. If the consequences of each option are presented properly, the reasonable patient will still make the right choice.
5.5The Ultimate Treatment Decision: “Whose Eye Is It?”
In my view the eyeball belongs to the patient and thus he has the right to make the final choice regarding treatment. The surgeon’s job is to supply the information so that the choice rests on a rational foundation, and both surgeon and patient feel comfortable with it (see Table 5.1).
Once the selection has been made, the patient should be given additional, more detailed, written information about it (informed consent). The document should discuss the following:
5.7 What if the Eye Has Two Diseases? |
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•The procedure itself: what actually happens during surgery. This is especially important if the surgery is under local anesthesia (see Sect. 15.2).
•The list of postoperative complications and their recognition, and what the patient should do if they occur.
•The patient’s responsibilities postoperatively, including medications and physical activities.
–It is unacceptable if the patient with a macular hole is told only after the operation that he needs to be facedown for several days.
Pearl
I try to not repeat it throughout the book, but in every case when the treatment is described for any condition, it is based on the VR surgeon’s reasoning. The ultimate decision, however, whether to go ahead with that option is the patient’s.
5.6Which of the Two Eyes to Operate on First?
Rather often patients are seen with the same chronic condition (e.g., ME or EMP) involving both eyes, even if the condition is more advanced in one eye. The question, once both eyes are determined to need surgery, is which eye should be operated on first.
•Operating on the eye with worse vision is what most surgeons recommend.12
•My suggestion to the patients – and I explain the rationale for this – is to select the eye with the better vision first. There are two reasons for doing this:
–If the worse eye is operated on first and vision does not improve according to the patient’s expectations, the incentive to subsequently operate on the better eye (with the better prognosis) may be destroyed (“why would my left eye improve if the right did not?”).
–The prognosis in the eye with better vision may worsen if surgery is delayed.
5.7What if the Eye Has Two Diseases?
If a patient is referred with, say, visual deterioration in an eye that has both dry AMD and EMP, it is impossible to determine which of the two diseases – one clearly an indication for surgery, the other not13 – is responsible for how much of the visual loss. I heard surgeons advising patients in such situations against having surgery.
12And patients intuitively prefer.
13Even though there are some early data that PPV may help in certain cases of dry AMD; my own experience is that if traction is found on the OCT, surgery can improve vision in dry AMD.