Less is more: Strategies to reduce chair time
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The premium surgeon is quite familiar with the phrase “overdeliver/underpromise” in their everyday exam lane refractive cataract evaluation.
No doubt achieving the best outcomes can take different approaches, but ultimately the road with reduced chair time leads to happier patients due to a more premium experience.
The phrase “less is more” is well-known, first popularized by minimalist architect Ludwig Mies van der Rohe in 1947, and has been interpreted in many ways. Enjoying my third year of hosting a private practice refractive cataract fellowship through SF Match, less is more has been my theme from day 1 with each fellow. Quality is more important than quantity, so quality time and the patient experience with the premium surgeon are more critical than the quantity of time spent. This less is more approach is best achieved once proper objective preoperative testing is achieved followed by the triad of applying friendly verbiage, setting patient expectations and using premium technology.
Proper objective testing
In order to establish the “perfect candidate” criteria for refractive cataract surgery, an array of diagnostic testing is critical. A pristine ocular surface, utilizing tear osmolarity (TearLab), MMP-9 (Quidel), dry eye questionnaires (OSDI, SPEED) and meibomian gland imaging, paves the way, but OCT imaging to rule out macular pathology (epiretinal membrane, age-related macular degeneration), corneal topography/tomography/epithelial mapping with devices such as Pentacam (Oculus) and Cassini (i-Optics) to show the ability to treat residual refractive error postop with either PRK, LASIK or SMILE, measurement of angle alpha/kappa and corneal quality in terms of higher-order aberrations (OPD III, Marco/Nidek), and utilization of fourth-generation IOL formulas (Barrett, Hill-RBF, Ladas, Holladay 2, Barrett True K, ASCRS calculator) with devices such as IOLMaster (Carl Zeiss Meditec), Lenstar (Haag-Streit), Argus (Movu) and ORA (Alcon) are important in the reduced chair time less-is-more process. Without proper diagnostics, presenting premium choices and setting patient expectations can never be achieved.
Proper verbiage
When talking to patients either in the exam lane or in the operating suite, certain wording can change the patient experience dramatically and save much needed chair time. An immediate example from personal experience: When a patient thinks a corneal suture on postoperative day 1 with cataract surgery is a complication, I use the analogy that closing the chest during heart surgery is just as important as sealing the incision so “eye contents don’t come out,” and so a suture is part of the planned cataract procedure. A second example is when patients compare the experiences of their two eyes; Dee Stephenson, MD, tells patients “eyes are not twins, just siblings.”
A third example is patients complaining of continued dilation of their pupil into day 2 to 3 postoperatively because the premium surgeon decided to use Omidria (phenylephrine 1% and ketorolac 0.3% intraocular solution, Omeros); I remind them that the pupil space is my operating window, and if small, I may be operating blind. Lastly, using lifestyle terminology such as “Legal to Drive” for distance correction (created by James Loden, MD) in place of astigmatism management and “Forever Young” (my creation) in place of presbyopia management is much more patient friendly without lengthy chair time to explain ophthalmic terminology that requires medical training.
Patient expectations
My favorite approach to reduce chair time and enhance the patient experience as a premium surgeon is simply by setting patient expectations preoperatively. A patient with a dense cataract with no view of the retina is the classic case in which if the surgeon ends up leaving a retained nuclear fragment in the vitreous, it suddenly becomes the surgeon’s fault. Just by telling the patient that their visual outcome will require two procedures in the preoperative evaluation to achieve a successful outcome, the premium surgeon suddenly becomes the hero with no chair time postoperatively if only one procedure is needed in the end, but if a second vitreoretinal procedure is needed to retrieve the retained nuclear fragment, that was the expectation already with no added chair time postoperatively. Also, use lifestyle questionnaires preoperatively, as premium surgeons will surprisingly find out unexpected psychological profiles of their patients and may adjust what premium options are offered to avoid unnecessary chair time postoperatively.
Premium IOL technology
Currently, my premium armamentarium includes Vivity and PanOptix IOL technology (Alcon) in my Forever Young category and the Light Adjustable Lens (RxSight) and enVista monofocal and toric IOLs (Bausch + Lomb) for my Legal to Drive category. Having a full armamentarium of IOLs expands offerings to meet the needs of each premium patient in a truly customized fashion; for example, Vivity may be the best option for a patient with a mild epiretinal membrane, and the Light Adjustable Lens may be the best option for establishing the correct amount of ametropia for a patient with monovision. Selecting the same IOL for all premium category patients could potentially lead to much unnecessary chair time postoperatively.
In the end, the less-is-more approach enhances both the patient and premium surgeon experience with minimal chair time and excellent customer experience and visual outcomes. Let us hope COVID becomes less and our herd immunity becomes more as we move forward in 2021. God bless.
- For more information:
- Mitchell A. Jackson, MD, can be reached at Jacksoneye, 300 N. Milwaukee Ave., Suite L, Lake Villa, IL 60046; email: mjlaserdoc@msn.com.
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