Science and art combine for improved patient outcomes

San Francisco-New technology can help ophthalmologists care for their patients if they combine it with a personal touch, said Paul P. Lee, MD, JD, in the Shaffer-Hetherington-Hoskins Lecture during the Glaucoma 360 CME Symposium.

“Wisdom comes from a combination, in one way of looking at the world, of combining the science that we have with the art of medicine,” said Dr. Lee, professor and chairman, Department of Ophthalmology, and director, W.K. Kellogg Eye Center, University of Michigan, Ann Arbor.

Listen as Paul Lee, MD, delivers the 2015 Shaffer-Hetherington-Hoskins Lecture on its entirety.

One lesson from science that ophthalmologists can apply is that early glaucoma entails no visual field loss. So ophthalmologists must assess the nerve and nerve fiber layer carefully.

In the European Optic Disc Assessment Trial, ophthalmologists from 11 European countries classified 40 healthy eyes and 48 glaucomatous eyes with varying severity on stereoscopic slides.

The ophthalmologists ranged in accuracy from 61% to 94%. The researchers concluded that common imaging devices outperform most clinicians.

“The reading centers are at least as good as the physicians,” Dr. Lee said. “Physicians tend to underestimate the severity of disease as compared with the reading centers.”

NEXT: Continued + Exclusive video of Dr. Lee

In an exclusive interview with Ophthalmology Times, Paul Lee, MD, JD, discusses his talk, 'Improving Patient Outcomes: Combining Science and Art," at Glaucoma 360.

Dr. Lee also urged his audience to look very closely at visual field changes.

He pointed out that Early Manifest Glaucoma Trial (EMGT) and Collaborative Initial Glaucoma Treatment Study (CIGTS) criteria both show more change than Advanced Glaucoma Intervention Study (AGIS) criteria for the same fields.

That makes sense because AGIS is intended for advanced glaucoma, “so to find the change it’s got to be a big change,” Dr. Lee said.

However, he cautioned practitioners to “use one method; don’t bounce back and forth.”

At the same time, changes in visual field should not govern a treatment plan. Instead, ophthalmologists should study and apply Bayes’ Theorem, a mathematical formula used for calculating conditional probabilities, he said.

One insight from the theorem is that one positive test result does not prove the presence of a disease.

“This is a really important concept for all of us,” Dr. Lee said. “There have to be at least two independent pieces of evidence that someone is getting worse. Don’t overact and change something because today’s visual field is getting worse.”

Another way clinicians can measure the progression of a patient’s glaucoma is to look at test results over a long period. He urged the audience to go back to field tests from 5, 10, or even 15 years in the past.

Once you find that someone’s glaucoma is worsening, look for factors that could explain the change, Dr. Lee suggested.

Many surprising factors can increase pressure, including yoga positions in which the patient spends time upside down, sleep position, tight neckties, isometric exercises, the Valsalva maneuver, playing a wind instrument, periodic water spikes, blood loss, syphilis, methanol, and hypotension, he added.

“So many of our patients are being treated for hypertension,” Dr. Lee said. “Try to keep the pressure from getting too low.”

Finally, Dr. Lee urged his audience to address patients’ expectations.

“Do we take the time to really listen to the patients and hear what’s bothering them?” he asked.

In one survey, patients rated technical expertise as the fourth most important skill in a practitioner, after honesty, diagnosis and prognosis, and clear language.

After receiving a diagnosis of glaucoma, patients worry about blindness, even if they don’t express that fear, Dr. Lee said.

He suggested that physicians can respond by offering this assurance: “If you do a good job of taking care of yourself and working with your doctor, we have every confidence that you will not go blind by the time you pass.”

He also exhorted ophthalmologists to learn cultural sensitivity and to be aware of widespread illiteracy.

“Take the last year of school completed, and subtract five grade levels to get someone’s level of literacy,” he said. “We know that people with poor literacy have poorer adherence and poorer results.”

Conversations with patients can reveal early warning signs that they might be thinking of switching to another ophthalmologist, Dr. Lee said.

“All of us are here because we love to take care of individual patients, and by taking care of individual patients we can improve the health of our population,” he said.