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Managing patient expectations
Chapter excerpt: Managing patient expectations is one of the most critical processes for success with presbyopia-correcting IOLs. This is accomplished in most cases through an interactive counseling process.
One of the most oft-quoted lines on the subject of counseling patients for presbyopia-correcting IOLs surgery is to “under-sell and over-deliver.” While the logic behind this aphorism is clear, it can unfortunately lead to difficulties for the surgeon just beginning to utilize presbyopia-correcting IOLs.
The problem with under-sell and over-deliver is that it can create a confusing situation in which the surgeon is trying to convey two disparate and conflicting messages to his or her patients: 1) This lens has problems and things you will not like about it, and 2) We should use this lens because it will work well for you and you will like it. If this approach is taken, the patient will often sense uncertainty either in his or her surgeon or, at the very least, in the support staff of the office.
The easiest way to resolve this paradox is to counsel the patient from a different perspective. One approach that can be helpful is the concept of “educate and manage expectations” rather than under-sell and over-deliver.
With the focus on educating the patient, the first step is to advise the patient with regard to what his or her visual function would be like if he or she chose a conventional monofocal IOL. If the patient understands the absolute presbyopia that accompanies emmetropia with a monofocal IOL and does not desire this situation, then he or she can at least be considered as a candidate for a presbyopia-correcting IOL.
There is no under-selling or over-selling in this approach; instead, the patient is counseled, or “educated,” regarding the potential benefits as well as drawbacks of presbyopia-correcting IOLs vs. monofocal IOLs. A basic approach to this is outlined below:
Physician: “Well, I understand you have decided to proceed with cataract surgery. You need to realize that with standard cataract surgery with a conventional lens you will see well in the distance without glasses, but you will need spectacles for all visual activities from arm’s length on in.
“If you do not want to have to wear spectacles for all visual tasks from arm’s length on in, there is a better surgical option. It is called (insert the name of the particular lens platform you would use) cataract surgery.”
The cornerstone in managing expectations and educating patients about presbyopia-correcting IOLs is really to educate them about what their other option would be like if they chose a monofocal IOL. We have all had the experience of operating on a patient for conventional cataract surgery who is perplexed as to why he or she needs reading glasses after surgery despite having been informed preoperatively “you will see well in the distance without glasses but will need them for reading.” This is because none of these concepts are instinctive or intuitive for our patients. It is our goal as surgeons to educate the patient preoperatively so he or she can understand the poor functional near vision that accompanies bilateral emmetropia with monofocal IOLs. The entire process becomes easier once patients understand that this is what things would be like if they do not choose a presbyopia-correcting IOL. Their expectation for presbyopia-correcting IOL surgery is that you will make them better than they would be if they chose a monofocal IOL.
In more than 95% of cases, you will dramatically over-deliver beyond this mark, and the patient will be extremely pleased. In the small number of cases in which this does not happen, you at least will not have over-promised. As a result with the approach of educate and manage expectations, you can deliver a coherent, unified message to the patient and yet still be able to under-promise and over-deliver. This frees the surgeon from having to under-sell the presbyopia-correcting IOL because he or she can appropriately educate the patient that the functional near vision will be better than that with a monofocal IOL. Yet at the same time, he or she can inform the patient of any potential concerns that might exist regarding the specific presbyopic platform he or she is utilizing.
What if a patient asks, “What is the biggest risk?”
I answer, “In some way, shape or form, you may not be happy with how you are seeing with the presbyopic lens in place. Conceivably, if you are frustrated enough with the vision, the procedure is reversible and the presbyopia-correcting IOL can be removed and a conventional lens put in its place. This would obviously require more surgery but is fortunately a rare event.”
Preoperative education and counseling are critical for success with any presbyopia-correcting IOL platform. The time commitment necessary to accomplish this becomes less as surgeons gain familiarity with their overall spectrum of clinical results. In addition, education and counseling, when performed appropriately, also make the entire process easier for both the patient and the surgeon. Ultimately, this saves significant time, as happy and satisfied patients are easier and less stressful to care for. Investing the time preoperatively and postoperatively to manage your patient’s expectations is extremely valuable, as it will allow you to achieve the highest rate of clinical success with your chosen platform.
Update on managing patient expectations
Premier Surgeon spoke with Richard Tipperman, MD, to find out how his approach to managing patients’ postoperative expectations has evolved over the past several years.
PS: What has changed since this chapter was initially published?
Richard Tipperman
Dr. Tipperman: There are a couple of things. When presbyopia-correcting lenses first rolled out, doctors talked about percentages of patients who were spectacle-free. I think the lenses were out for about 2 weeks when people realized that probably was not the best way to discuss this. When I talk with patients now, I have moved even further from letting them think that any lens is going to prevent them from ever having to use reading glasses again.
Michael Wong, MD, of Princeton, N.J., coined the term “casual nearabilities,” because there is a lot of near work people do day in and day out besides reading, such as looking at their watch, looking at their cell phone, looking at the speedometer, being handed a flyer to read, going shopping. With regard to this, I think the mainstay of managing expectations is comparing what life would be like if the patient went with a monofocal implant for surgery. One of the things … I say to patients is, “If you go with a monofocal lens, I guarantee you every time you do one of these tasks, you’re going to be reaching for reading glasses. If we go with a multifocal lens, you’re going to have much more flexibility with your casual nearability.” It might not seem like a big deal, but instead of just honing in on the idea that the patient will not need reading glasses, it is really about describing the flexibility in the casual nearabilities patients gain with a multifocal implant.
Another huge change for me is the module David Chang, MD, scripted for Eyemaginations. In terms of patient education and managing expectations, it is one of the best things I have ever seen. It is very brief, and it is easily understood by patients. They get comfortable with what they can expect from the lens, and that has been very helpful.
The final thing that has changed is that I now say to patients, “I don’t put these implants in everyone, but for the patients I put them in, 90% to 95% of people are really very happy, 5% to 8% are good but wish they were better, and probably 1% to 2% are really frustrated with the performance and how they’re doing. The good news is for those folks, the procedure is completely reversible and the lens can be swapped out.” This is not a discussion I used to have with patients.
PS: What role does patient selection play in the interactive counseling process you mentioned in your chapter?
Dr. Tipperman: I still look for patients who have healthy eyes and are likely to need bilateral surgery. There is a lot people think about personality profiling, but I say the pickiest patients in the world are happy if they get a good result and the most easygoing person in the world is not happy if they do not get a good result. This still is very results-driven.
We use a modification of the Dell questionnaire that is very brief and asks patients whether they would like to function for distance, mid-range or near without glasses. At the bottom of the questionnaire, we list their astigmatism and include their lens options: basic monofocal implant, toric implant and multifocal lens. Based on what they are looking for, we talk to them about what the different options would be. Not a lot of other high-level personality profiling.
Patients have changed a bit, too. There has been a learning cycle on the doctor’s behalf since these lenses were introduced, but one thing we do not realize is there has also been a learning cycle on the patients’ behalf. It is not just that ophthalmologists are beginning to know more about these lenses, be more aware of them and use them more, it is also that patients are becoming more aware of them as an option and more aware of this concept of a hybrid payment system, which initially was met with a lot of resistance.
PS: Why do you recommend staying away from the “under-sell and over-deliver” approach?
Dr. Tipperman: The concept is good, but it ends up sending a very mixed message, especially when surgeons are first beginning to use these lenses. That is why I try to tell people to think of this more as educating patients about choices. The mantra in our office has remained, “Monofocal cataract surgery will leave you very dependent on spectacles for all your functional near work, and if you don’t want that, we have something better.” That is a goal we can always deliver with the technology. So, rather than under-selling and over-delivering with the lens, I like to tell patients, “You’re going to have cataract surgery anyhow, so here are the two choices you have. Which is going to be a better option for you?”
PS: As premium IOL technology has continued to develop, how has your approach to patient education adapted?
Dr. Tipperman: In terms of education for discussing glare and halo with patients, the Eyemaginations software does it in a very nice way; however, there is also a nice picture I have that shows cars in a parking lot with their headlights on. It shows some splay of the light from the headlights, but the cars, the lines in the parking lot and the trees in the background are all in focus. If you just tell patients, “Well you might have glare and halo,” the patients all say, understandably, “I don’t want that. I have a cataract, why would I want that lens?” But if you instead show them a picture and say, “This is what you might see with lights that can be splayed a little bit, but notice how everything else is in focus,” then patients understand what you are talking about.
PS: What are the most important steps to educating patients for surgeons just starting out with premium lenses or those looking to increase their conversion rates?
Dr. Tipperman: Although you can definitely put these lenses in unilaterally, patients are happiest when they are bilaterally implanted. So, one thing is to let patients know they are going to do best once they are bilaterally implanted. It is also important to make the patient realize it is going to take awhile to get used to this visual system and how it works, so it could be several weeks before their reading vision is as strong as you want it to be. That is still a little bit of the under-sell and over-deliver approach, because most patients are reading pretty comfortably within a week or two, but that discussion helps both the patient and the doctor.
Richard Tipperman, MD, can be reached at Ophthalmic Partners of Pennsylvania, Pagoda Building, 100 Presidential Blvd., Suite 200, Bala Cynwyd, PA 19004; 484-434-2700; fax: 610-660-0419; fax: rtipperman@mindspring.com.
Disclosure: Dr. Tipperman is a consultant to Alcon Laboratories.