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‘They’ said: Your patient listens to anyone and everyone
Dry eye disease doctors must overcome the power of 'They' when treating patients.
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The best dry eye disease care occurs after a systematic evaluation of each individual’s particular set of symptoms, exam signs and point-of-care testing results. Success is achieved most often when a patient receives a care plan that inserts these individual factors into an established treatment protocol based on a combination of known best practices and the experience of the eye specialist who is leading the DED care team. Once instituted, the care plan is then re-evaluated after a reasonable trial period to determine if it is effective. At that point, perhaps some tweaking to the formula might improve the outcome for the patient. On first blush, those of you reading this statement who do what I do — take care of DED patients — are probably wondering why I even bothered to write it down because it is so painfully obvious.
Well, it may be obvious to us, but “They” have yet to have their say, and “They” are all too often who your patients actually listen to.
The influence of ‘They’
I fired a DED patient the other day because “They” convinced her to change pretty much my entire treatment plan for her. Now, you may find this a bit harsh, but believe me, I did not do so lightly. Like many of you, I live among my patients, and this particular patient is one degree of separation from my family and me at least 100 times. She may very well be unhappy that I have declined to care for her DED going forward, and in all likelihood this unhappiness will travel through all of those one degrees of separation. However, let me point out that this was the third consecutive visit during which this particular patient not only failed to adhere to the prescribed DED regimen, but she outlined precisely why she had deviated from the regimen, complete with naming the roster of “experts” who had advised her to do so.
A nurse practitioner who attends the same yoga class told her that she simply had to change from re-esterified fish oil to a plant-based oil lest she succumb to heart failure (this despite her internist’s delight at her soaring HDL since starting the fish oil). Seriously, the NP said that. In an article in Consumer Reports or some such, “They” said that all artificial tears are the same, so out with the non-preserved oil-based tears and in with the coupon-boosted store brand. Dr. Google put the final nail in the coffin for my proposed treatment plan with a word or 200 about how chronic steroid use is tantamount to physical abuse (she had previously rejected Restasis after “They” said someone they knew heard about someone’s neighbor who did Pilates with a hirsute woman taking cyclosporine A for her kidney transplant).
In truth, by declining to be her DED doctor I was only pointing out that I had not really been her doctor at all; she was listening to what “They” said all along.
While the issue of patient adherence to medical therapy is an eternal issue faced by all physicians who care for chronic disease, I do believe that DED patients are among the most difficult to manage in this regard. I have written several times about the particulars of the dry eye patient personality, notably in the columns on the Hundred Acre Wood in which I compared dry eye archetypes to characters in Winnie the Pooh and in the multiple articles in which I have invoked our classic dry eye patient, “Linda Blair.” There is a certain combination of desperation and exasperation that depletes these individuals of whatever minute stores of patience they might have and drives them into the outstretched arms “They” hold open.
Changes in successful patients
What makes this all the more interesting, and from the standpoint of the DED doctor all the more maddening and hard to understand, is that the “too many cooks” phenomenon is not moored to the concept of success. It is not too hard to understand a patient jumping ship when symptoms are either difficult or slow to resolve. I do get that. It is the successful patients who puzzle me. Changes in how prescribed medications are covered may shake even the greatest success stories. Months or even years of comfortable eyes or stable vision are routinely cast aside at what can seem like the tiniest inconvenience involved in the treatment or its coverage. Direct-to-consumer marketing may plant the seed of doubt in a patient who is simply sailing along without incident and is now convinced that the waters of care are mine-infested. Your successful regimen has been the same for months or years. Something must need to be changed! “They” said so!
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Imagine for a couple of moments how this might play out in other areas of medicine in which chronic disease is also the waters on which doctors and patients float together. A brittle diabetic patient who took 10 years to achieve control on a particular type of insulin decides to “borrow” a relative’s extra medicine, even though it is a different insulin entirely, because it is free. The Wall Street Journal publishes an article on the pain-relieving qualities of curcumin, a substance found in turmeric. Tired of the injection schedule of her biologics, the elderly woman with severe rheumatoid arthritis stops all of her medicines in favor of a pill she can get at GNC. The problem exists in other parts of our eye care world, too. How many retina specialists do you think have had to defend the switch to Lucentis or Eylea when Avastin stops working, once the patients have seen a CMS report on payments to eye doctors?
The reality is that adherence is a fragile thing under the best of circumstances. Chronic diseases such as DED seem to create specific challenges due to both the difficulties inherent in diagnosing and treating them, as well as how common they are. Our world is evolving in ways that make it ever more difficult for us to fight this. The financial realities of treating common chronic diseases continually work against our best efforts. “They” used to have to actually be with your patient to have some influence or at least be somewhere your patient went. Social media now surround our patients. “They” are everywhere.
While I am certainly not planning on firing any more patients because of this, there might be a little bit of hope, at least for me. As I noted in my article on treating DED in the surgical patient, I am in private practice with lots of control over my day-to-day experience. Thinking about this reminds me of a conversation I once had with my sister. Sister: “How much vacation time do ‘They’ give you?” Me: “Tracey, I am ‘They!’”
Maybe I have a chance after all.
- For more information:
- Darrell E. White, MD, can be reached at SkyVision Centers, 2237 Crocker Road, Suite 100, Westlake, OH 44145; email: dwhite@healio.com.
Disclosure: White reports he is a consultant for Bausch + Lomb, Allergan, Shire and Eyemaginations; is on the speakers board for Bausch + Lomb, Allergan and Shire; and has a financial interest in TearScience.