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5 The VR Surgeon’s Relation to His Patient: Counseling |
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Proper counseling and not an outright rejection should be the VR surgeon’s answer. The patient must be told that surgery has risks and cannot promise to bring improvement – but that there is a chance, if the operable condition was the main culprit14 causing the visual deterioration. Again, it should be the patient’s decision whether to opt for surgery or not.
5.8What if the Eye Has Severe Visual Loss and the Chance of Improvement with Another Surgery Is Low?
Performing another operation – say, on an eye that had multiple surgeries for PVR and has an inferior RD despite a previous retinectomy and a circumferential SB – raises serious questions.
•The new operation may not improve the situation.
•Even if anatomical success is achieved, vision may not improve.
•The patient may have to endure a long operation and the inconvenience of pain, irritation, need for topical and probably systemic medications, and a very small risk of sympathetic ophthalmia (see Sect. 63.9).
Conversely, the only way to give the eye and thus the patient a chance is via another operation.
Q&A
QWhat if the patient refuses to even consider another operation because, based on his previous experience, there is no hope – but the surgeon is more optimistic?
AI tell my patients: “Do not give up until I give up; as long as I see reasonable hope for improvement, I am willing to offer a chance unless you categorically refuse.”
5.9Empathy: The Single Most Important Component of Counseling
One definition of empathy is “the ability to understand and share the feelings of another.” It means that the VR surgeon sees before him a person, not a disease, but it also means a lot more. He must appreciate what is going through the patient’s mind at the time of the examination and during the decision-making process (see Table 5.2). The patient:
14 Which is largely unknown at the time of decision-making. I tell my patients that there may be a chance for improvement with surgery but no chance without.
5.9 Empathy: The Single Most Important Component of Counseling |
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•Is anxious, worried, and nervous about whether the eye will go blind.15
•Has doubts about whether he is making the right choice regarding the therapy.
•Is scared of how a “blind eye” will impact his and his family’s life.16
Throughout the entire duration of the patient-physician relationship, the VR surgeon must help the patient deal with these hard issues; no person should become a physician if lacking empathy and being able to show it. Feeling empathy is either part of the personality or it is not; demonstrating it properly is a learned skill.
The VR surgeon rather often has a patient who is in a grave situation: vision in one eye is already lost and the prognosis in the fellow eye is very poor. Such a scenario presents a unique challenge regarding surgeon behavior.
Table 5.2 The person vs the condition as the target of counseling*
Example |
Comment |
A 19-year-old professional |
I once polled an audience of over 300 ophthalmologists about what |
boxer presents with a |
they would tell this patient. With the exception of two (who said |
trauma-related RD. He |
they did not know what they would say), everybody in the lecture |
undergoes PPV with laser |
hall said they would “forbid” this. The problem is twofold |
cerclage and gas |
First, we do not know whether the eye that now underwent |
tamponade. Once the gas |
vitreous removal and prophylactic laser treatment (see Sect. |
absorbs and he is deemed |
30.3.3) has an increased, identical, or lower risk of RD than |
cureda, he wants to know |
preoperatively or than the untreated fellow eye, if again |
whether he can continue |
exposed to the direct and indirect trauma that boxing represents |
his boxing career. Laser |
Second, the boxer earns his living by boxing; it is not a hobby for |
cerclage has also been |
him. It is easy for the VR surgeon to categorically declare “no |
applied to the fellow eye |
boxing anymore,” and the surgeon himself will certainly sleep |
|
better at night – but his brief sentence changes forever a |
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young person’s life, dreams, and livelihood |
A 70-year-old female farmer |
For her the chickens are crucially important not only as a food |
came to see one of my |
source and as a way to make a living but also because she is |
colleagues with an acute, |
emotionally attached to them. Furthermore, she has no idea |
macula-off RD. He told |
what a retina is or what the implications of the treatment or its |
her that she needed |
delay would be |
immediate surgery; the |
The VR surgeon must appreciate her side of the story and |
lady said she couldn’t |
explain to her in a language that is clear to her the essence of |
stay because nobody |
her condition, the risks and benefits of early treatment, and the |
would take care of her |
consequences of the delay. If she understands these, she can |
chickens. He screamed at |
go home, find someone to take care of her chicken while she |
her that her retina was |
is in the hospital, and then come back for the treatment as |
more important than her |
soon as possible |
“stupid chicken” |
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*Both examples are taken from my own experience; they are used to illustrate the point of why the person and not a tissue, the eyeball, or the anatomical abnormality should be the primary focus of the VR surgeon’s attention.
aMinus the very small possibility of RD due to unaddressed traction (see Chap. 54) or a more pronounced risk of PVR (see Chap. 53).
15People rarely ask: “Will the eye go blind?” They typically ask: “Will I go blind?”, as if the condition were bilateral, even when the fellow eye is healthy. Perhaps this choice of words reflects the extent of the patients’ anxiety level.
16Job, financial support, everyday activities etc.
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5 The VR Surgeon’s Relation to His Patient: Counseling |
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Pearl
Empathy can easily turn into a paralyzing force if the surgeon cannot find the right balance between his empathy toward the patient vs his emotions about the patient’s sad fate. Empathy should not be allowed to prevent the surgeon from doing his job.
Physical touch – squeezing a patient’s hand or hugging him – can convey warmth, understanding, and togetherness; it shows how much the physician understands what the patient must go through. Such gestures can go a long way in reassuring the patient that the surgeon is “with him all the way,” but it can be offensive in certain cultures.17
5.10The Prognosis with the Chosen Surgical Option
Every patient’s most important question is, whether he voices it or not, the expected final outcome. Even if hard numbers are available from the literature or the surgeon’s own clinical practice, and the prognosis is good, it is advisable for the VR surgeon to be cautious and never promise success.
Pearl
When informing the patient about the expected outcome (success rate, final visual acuity), it is best to be slightly on the pessimistic side. Pessimistic, because it is psychologically more preferable to have an outcome that is better than expected, than the other way around; and slightly, because too much pessimism may deter the patient from surgery when in fact it has a reasonable chance of success.
Deciding for surgery is relatively easy when the prognosis is good or surgery can arrest a condition’s otherwise inevitable worsening.
Q&A
Q What if the prognosis of the condition is poor?
AThe question is primarily decided by the difference between outcomes based on the natural history vs with surgery. If with surgery “there is nothing to lose” but there is at least some hope, and the complication risk is acceptable, surgery to the willing patient should not be denied. The patient must, however, understand that the loss of vision may be slow if nature takes its course but rapid or even instantaneous with surgery (due to complications).
17 Forbidden in the Muslim world if the surgeon is a male and the patient a female.
5.13 To Say It or to Keep Quiet |
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5.11If the Patient Chooses to Undergo Surgery
The surgeon should give a brief but proper explanation of the surgery itself. This is especially important if the operation will be under local anesthesia: the patient must appreciate why any movement during surgery can have deleterious consequences. As an example, it is impossible for a layperson to understand that “the ILM is 2 μ thick,” but they immediately perceive the implications if the ILM thickness is compared to that of the human hair (see Sect. 15.2).
5.12The Benefits of Proper Counseling
As described above, proper counseling is difficult to learn and practicing it is very time-consuming. It does, however, offer several advantages for the surgeon, making it a rewarding experience:
•The patient becomes a partner and remains one during the entire treatment process.
–He understands the difficulties the surgeon constantly faces practicing his profession and how little this leaves for having a personal life.
–He is more likely to follow instructions, cooperate in positioning and taking his medications, and return for follow-up visits.
–It is more likely that he will return for a follow-up visit not only when problems arise but also if surgery was successful.
•If a patient was treated like a partner, like an individual, and not a tissue pathology, he is less likely to sue his doctor if something goes wrong.
It must be emphasized again and again that the reason I am arguing in favor of letting the patient – rather than the surgeon – “indicate” surgery is not due to a desire to escape the responsibility of making a decision. It is difficult to make decision, but the surgeon makes hundreds of decisions every day. However, to make the patient a true partner, it is best to let him make the most difficult decision: to operate or not.
5.13To Say It18 or to Keep Quiet19
A 70-year-old patient with severe diabetes arrives; his parents also had the disease. He comes with his 40-year-old son who is very fat. Are you going to tell the son, who is technically not your patient, that he is also at risk of developing the disease and that he must lose weight and exercise to do his part in reducing the risk he faces? (Personally, my answer is: Yes, I will.)
18Because you are a physician, who sees the forest, not only the tree.
19Because you should not poke your nose into how other people live their life (see the Appendix,
Part 2).