Taking the sales pitch out of cataract surgery consult

Take home

When consulting with patients who present with decreased vision due to cataracts, ophthalmologists need to remember their role as physicians first, suggest the authors. The primary goal of the office visit is to address the complaint and the solution in entirety before moving into outcomes.

By Paul S. Koch, MD, and Lawrence Piazza, MD, Special to Ophthalmology Times

Rapid advances in ophthalmic technology provide physicians with an arsenal of tools to treat patients. Armed with a wealth of technical data, brochures, and pitches from product sales representatives, surgeons may find themselves touting the features of premium lenses to their patients.

It is time to take the sales out of the discussion of cataract surgery. We are physicians first. The priority is to address the reason why patients have presented-decreased vision from a cataract. With the goal of patient satisfaction, we have collaborated to produce a guide to help physicians develop the best surgical plan for the patient-without playing the role of salesperson.

The cataract discussion

Outcomes matter to patients, not product specifications. By shifting the approach from a discussion about products to the actual needs of the patients, ophthalmologists can expect informed patients with realistic expectations who are equipped with the information they need to make decisions confidently regarding their eyesight.

This helps ensure that patients who will receive the most benefit from these products understand the value added to them, and that patients who will not receive a great benefit, or perhaps even experience a negative effect, recognize this and do not naively purchase a product that will ultimately fail to meet their expectations. We find it effective to educate patients in advance of their appointment by providing literature about what to expect during the exam, along with product-neutral brochures or web links with information about surgical procedures and lens options.

During the examination, physicians must keep forefront that patients came to our office to address the problem of vision loss from a cataract. First, determine whether cataract surgery is warranted. Assuming the patients elect to have this surgery, assure them they will see better after the procedure. It is imperative to take the time to ask patients if they have any questions and to ensure that they understand about cataracts and the surgery before discussing IOL choices. If we have effectively done our job of addressing the patients’ problem, they should never have to ask: “But will I see better?”

The lens discussion

With patients’ concerns thoroughly addressed, and before a surgical plan is developed, attention is turned toward the desired outcome. During this portion of the consultation, we are only interested in patients’ visual wants and needs as their lifestyle and expectation are assessed. Do not bring up brand names or the terms “toric” and “multifocal.”

We like to introduce the topic with a statement such as: “Let’s talk about surgical outcomes before I plan your operation. Tell me how you use your eyes and how you would like to use them after surgery.”

This question might catch your patients by surprise. Expect an uncomfortably long silence-wait. Do not say anything. Let the patients think. Eventually, they will say something like: “I watch television. I knit. I drive. I read before bed.”

That is what they do. Now you have to learn how they do it.

The following series of vignettes demonstrates our tested and effective method of directing the conversation with patients to determine their needs and desires for their postoperative outcome.

Scenario 1: Glasses

Patient: I don’t mind using glasses.

Physician: You will see a lot better than you do now when you get your new glasses after the operation.

Scenario 2A: Reading glasses, no astigmatism

Patient: I prefer not to wear glasses all the time, but I don’t mind reading glasses.

Physician: Nine out of 10 times, we can get good overall vision without glasses. You will just need reading glasses.

Scenario 2B: Reading glasses, astigmatism

Physician: We can try to get you good overall vision without glasses so you will only need reading glasses. However, your astigmatism poses a bit of a problem. We usually correct astigmatism with eyeglasses, but I can correct the astigmatism during the operation, which makes your vision as good as we can possibly make it. Unfortunately, insurance does not cover treating astigmatism. There will be an added charge, but I think it will be worth it.¹

Scenario 3A: No glasses, no astigmatism²

Patient: I do not want to wear eyeglasses.

Physician: We can implant a special bifocal lens that will help you see far and near without glasses. Nine times out of 10, the patient does not need to use eyeglasses at all after surgery. The tenth patient still needs to use glasses at least occasionally, depending upon available lighting and visual tasks. There are three important things you need to know:

·      This lens works. The focus point is 10 to 12 inches and does not move. If you want to see something farther away, like a computer screen, you may need to make small adjustments to get it in the focus range. Some people keep a pair of computer glasses next to the monitor to make it easier for them to see at that intermediate distance.³

·      When you go out at night, you will see rings around lights because of the lens design. It is not bad and most patients adapt to this by 4 to 6 months after surgery.

·      Insurance companies consider “getting out of glasses” a luxury and will not cover this type of lens. You will have to pay a portion out-of-pocket.

Scenario 3B: No glasses, astigmatism

Physician: We can do this, however, your cornea has quite a bit of astigmatism so I do not think I can get you out of glasses completely. I am going to correct the astigmatism to give your best distance vision, but you will probably need reading glasses.

At this point, the physician can also discuss the options of monovision or a multifocal implant if the patient’s astigmatism is treatable with limbal relaxing incisions (LRI) (manually or with femtosecond laser). If astigmatism is too high for LRIs, then after 6 months, the patient might consider PRK to correct astigmatism.

Conclusion

When we, as physicians, understand that patients come in with the problem of decreased vision due to cataract, the solution is cataract surgery. The primary goal of the office visit is to address the complaint and the solution in entirety before moving into outcomes. To bring up anything before the issue of cataract surgery is resolved will make patients feel cheated.

Patients often have expectations different from what physicians might think, particularly when thinking in terms of technology. We must remember to see these technologies as just tools to arrive at what the patient really needs. We are physicians first.

Paul S. Koch, MD, specializes in cataract, lens implantation, and refractive surgery. He is a founder and medical director of Koch Eye Associates with offices located throughout Rhode Island. Dr. Koch can be reached at 401/738-4800.

Lawrence Piazza, MD, specializes in advanced refractive cataract surgical techniques and customized IOL surgery, as well as the management of surgical eye disease at his practice, Coastal Eye Care PA, located in Maine. Dr. Piazza can be reached at 207/667-6300.

Notes

1. Dr. Koch uses toric lenses because of the predictability in treating astigmatism.

2. In this scenario, “no astigmatism,” means anything from zero to a minor astigmatism, correctable with a single incision LRI to get it less than 1 D. In general, up to about 1.75 D of against-the-rule astigmatism, or 1.25 D of with-the-rule astigmatism.

3. This response enforces the excellence of the close vision, but lets patients know that this is not a universal focus lens. Some people will still require glasses for specific tasks, and that is okay.