1. Apr 16,2019

AAO: How to Handle the Unhappy Cataract Surgery Patient

The preoperative discussion is crucial, but what do you do when dissatisfaction persists postoperatively—and how do you handle patients who cross the line?

It is easy for high-volume cataract surgeons to get used to having happy and satisfied patients, given the tendency for very good outcomes. Every now and then, though, someone is going to be dissatisfied, and you are going to have to deal with the situation. Even when the patient crosses a line, the onus is on you to diffuse the situation and make things right. So says Susan MacDonald, MD, associate professor of ophthalmology at Tufts University School of Medicine in Boston.

She speaks from personal experience. Dr MacDonald had a 76-year-old male present with decreasing vision and asymmetrical cataracts, greater in the right eye (20/60) than in the left (20/25). “We discussed the risks and benefits of cataract surgery,” she explained. “He told me straight out, ‘I do not want one of your fancy lenses, so I don’t want you to sell me anything that I don’t need.’” (Reader: make a mental note of this dialogue, which we will refer back to later.)

Dr MacDonald proceeded with phacoemulsification and an aspherical intraocular lens (IOL). Postoperatively, his uncorrected visual acuity was 20/80 in the right eye. “But this was easily corrected to 20/20 with correction,” said Dr MacDonald.

The patient’s chief complaints after surgery, which were aired in the waiting room in the presence of other patients, became progressively worse with each follow-up visit. Initially, he reported being unhappy with his vision. He said he never had to wear glasses before, then said his vision was worse than before surgery. At one visit he crossed the line, announcing, “I never should have let a lady operate on me. I want to see a man doctor.”

Straightforward Problem…But ‘A Lot to Unpack’

“That’s a lot to unpack,” admitted Dr MacDonald. Ironically, “the patient’s clinical issues were fairly straightforward. He had [1.75 diopters of] against-the-rule astigmatism preoperatively that was being corrected by his lenticular astigmatism. He really just needed to have limbal relaxing incisions (LRI) or a toric lens and he would have had perfect 20/20 vision.”

Dr MacDonald chose to send the patient to a male colleague, who performed astigmatic keratotomy. “His postop course was very simple with a nice refractive error.”

All’s well that ends well, right? Clinically, perhaps, but Dr MacDonald mulled over what she could have done differently from the start. “When the patient said he did not want a fancy IOL, I made an assumption that I didn't have to have a [detailed] discussion about the fact that if I didn't put in a toric IOL, I was going to make his vision worse refractively, and make him more dependent on glasses.”

So, the lesson is that when a patient tells you not to ‘sell’ him or her anything unnecessary, be sure that does not stop you from weighing in. Say you appreciate his or her perspective, and here are the pros and cons of proceeding under different scenarios.

As far as the patient crossing the line with an inappropriate gender-related comment, Dr MacDonald said she addressed the issue this way: “I told him, ‘you know, I think you have some very valid concerns, but I really don’t think what happened had anything to do with my gender.’”

If you find yourself in this situation, it is, of course, important to stay professional. Emotions can get high when the patient is angry. It’s easy to become defensive, particularly when you know that you did nothing wrong procedurally. Some patients are bound to be dissatisfied. The best option is a thorough discussion preoperatively, reviewing all the potential outcomes, along with appropriate signed informed consent.

That’s not going to make dissatisfied patients totally disappear, nor should it. But it will allow for a more sensible postoperative discussion with those who are not completely satisfied.

 

Reference

MacDonald D. How to handle the unhappy patient. Talk presented at: AAO 2018 annual meeting; October, 26-30, 2018; Chicago