Dissatisfied LASIK patients can be handled, prevented by using honed communication skills

Key Points

Atlanta-Skillful physician-patient communication is paramount to successful prevention and management of dissatisfied LASIK patients, said Jennifer Morse, MD, at the American Academy of Ophthalmology annual meeting.

"Communication is not just a skill physicians learn in medical school. As with surgical skills, communication skills need frequent updating and practice so that they can be maintained and improved," said Dr. Morse, a psychiatrist and communication skills consultant in San Diego.

She provided some tips for optimizing communication along with evidence from published literature supporting their role and also discussed other factors that can influence surgical patient satisfaction.

In speaking with patients, physicians need to be mindful of their verbal and nonverbal cues, she said. Supporting this recommendation, Dr. Morse cited a published study showing a relationship between surgeon tone of voice and malpractice complaints.

Affective empathy is another skill that must be consistently demonstrated in all physician-patient interactions, whether dealing with individuals who are satisfied or dissatisfied, she said. The value of empathy is suggested by the results of a Danish study in which the higher level of physician empathy correlated with the increased ability of patients with cancer to cope with their symptoms.

With the aim of understanding the dissatisfied patient, an approach based on listening more and talking less is necessary, Dr. Morse said. The verbal contributions of the physician should concentrate on asking appropriate questions that serve two primary purposes: helping patients feel comfortable in expressing their dissatisfaction and the underlying reasons for it, and learning what the patient considers to be a satisfactory outcome.

"Providing patients with reasonable expectations preoperatively is an important factor in achieving satisfaction postoperatively, but it is also critical to understand what the patient considers to be a satisfactory outcome," she said. "Surgeons need to investigate what satisfaction means to each patient rather than applying their own beliefs about what should be acceptable."

Dissatisfied patient model

Beyond the issue of communication, substantial research in other surgical specialties demonstrates the importance of patient psychosocial factors on surgical outcomes, Dr. Morse said. The personality of the surgeon and office staff also can influence patient function and satisfaction postoperatively, however, she added.

"Remember in your office, there are two personalities interacting: the patient and you or your staff, and there has been an interesting study showing that patients prefer certain personality characteristics in their physicians," Dr. Morse said. "Patients in that study reported higher satisfaction with physicians who scored higher in openness (e.g., open people are more sensitive to nuances in feelings) and only average in conscientiousness."

In collaboration with Capt. Steve Schallhorn, MD, Dr. Morse conducted a prospective study to examine the effect of personality and psychiatric factors on patient satisfaction with visual quality after LASIK. Presented originally at the most recent annual meeting of the American Society of Cataract and Refractive Surgery, the study included 308 patients who underwent bilateral conventional LASIK at the Naval Medical Center, San Diego.

The patients completed a personality inventory preoperatively and were stratified into "low," "medium," and "high" groups based on negativity and depression scale scores. The patients also were stratified by level of satisfaction as "highly satisfied," "satisfied," and "less satisfied."

The analyses showed that patients with higher scores on the negativity and depression scales (greater number of symptoms) had a three-times greater likelihood of being less satisfied with their visual quality at 1 month postLASIK as compared with those with low negativity and depression scale scores. The same trend persisted when satisfaction was evaluated at 6 months after surgery.

"This is an interesting finding, but it is from a preliminary study," Dr. Morse said. "Validation is needed from a study designed to include a larger, more diverse population so as to provide a larger number of dissatisfied patients. That study should also include preoperative and postoperative measures of depressive symptoms and negativity to allow for assessment of change in level of symptoms postLASIK."

Pain is another factor that can influence patient satisfaction after surgery, she said, and although more research in this area clearly is needed, it is worth considering that pre-existing chronic pain, regardless of its source, may have an influence on postoperative reactions and satisfaction. Acute and chronic pain also can affect patient understanding and recall of informed consent; patients in pain may experience decreased attention and concentration.

Dr. Morse said that in chronic pain, the routing of pain signals within the dorsal horn and pain modulation is altered so that patients may become more sensitive to lower levels of pain stimuli. Further research is needed to understand individual differences among patients in response to identical levels of pain stimuli, she added.

"LASIK patients don't typically experience much acute postoperative pain, but this is a relevant issue as it relates to dry eye-related complaints," Dr. Morse said.

"It is critical to understand that pain is an individual experience, and while it is easy to conclude that patients must be embellishing their pain when the level of their complaints is considered inconsistent with clinical measures, you really can't make that judgment," she continued. "Surgeons must never give the cue that they are discarding or minimizing patient complaints based on their personal experience and exam findings."