COMMUNICATING WITH PATIENTS

Connecting Through Conversation

Retina specialists share best practices for communicating with patients and caregivers

BY ERIN MURPHY, CONTRIBUTING EDITOR

Retina diseases are both complex and hidden, which means it takes skill to educate patients. Patients may not have heard of age-related macular degeneration (AMD) or diabetic macular edema — or even the macula. Certainly, most people have never had a reason to learn about intravitreal injections or macular hole repair. You’re starting from the ground up, and you typically have limited time to make patients understand their diagnoses and treatment options. New Retinal Physician asked two experienced surgeons to share how, even under time constraints, they are able to communicate with patients in a way that builds relationships and engenders confidence in their care.

Developing patient communication skills takes time. What advice would you offer to physicians in their early years of practice?

Charles C. Wykoff, MD, PhD: When I started out, the only specific idea I had in mind was that it’s all about the patient. I spent time learning about each person, and I found that my patients were incredibly valuable teachers. They taught me to be a better physician. If you learn about the person, not just the OCT, it’s easier to bond with your patients and understand what they’re going through. You learn the challenges that vision problems create in their daily lives. That helps you tailor treatment to each patient, and it helps give context and meaning to your work.

In addition, your patients will be much more satisfied if you focus on them and listen rather than if you just tell them if the OCT shows dry or wet macular degeneration. This is always important, but early in your career, happy patients can help you build your practice. Don’t underestimate the power of a peer-to-peer reference. Patients in the community who are happy with you and your care are incredibly valuable.

Seenu M. Hariprasad, MD: When it comes to patient education, I’m still learning and trying to get better. It’s all about the balance between ensuring patients are confident and well informed and maintaining the level of efficiency you need in your practice.

To start, it’s important to treat every patient as you’d want a doctor to treat your mother or grandfather. Protect their dignity, express respect, and make sure all of their questions are answered. I’m as rushed as anyone else, so I have to get the message across fairly quickly, but I have to do it in a way that doesn’t make the patient feel slighted.

One way I save time is to type my notes in the room with my patients while I answer their questions. The charge tickets are complete, and the patient gets a longer visit. If a patient needs a great deal of time and I’m concerned we might get backed up, I say, “We have patients waiting right now. Can I take your number and call you when clinic is finished?” They see how busy the clinic is, so they understand. It’s a good way to be both respectful and efficient.

What strategies help you get a point across quickly?

Dr. Hariprasad: Diagrams, pictures, eye models, and OCT images can be very helpful for patients to understand their problems. I give them copies to take home and refresh their memories.

As a conversational strategy, analogy is very useful. I might say, “If this room is an eye and we’re sitting inside the walls of the eye, the wallpaper is the retina. Scar tissue is forming on the front of the retina and affecting your vision.” I don’t want to dumb it down to the point where patients find it insulting, but I do want to illustrate the point in their minds.

Dr. Wykoff: I like to use analogies as well, comparing the problems we manage to familiar things, such as automobiles or even other medical diseases. For example, I explain that the treatment pattern for wet AMD is similar to that for high blood pressure. Patients understand that we treat high blood pressure with pills that lower it to a normal level. If a person stops taking the medication, blood pressure goes right back up — the pills are not a cure. In the same way, individual injections work very well for AMD, but, unfortunately, the injections are not a cure in most circumstances. The eye will need multiple injections through many months or years, and interrupting treatment often results in a return of disease activity.

In addition, people like focused attention, which I try to achieve in my practice by using a scribe while in the room with patients. I try to look at patients or their caregivers almost 100% of the time while I dictate to the scribe what I see — the history, examination, diagnosis, and management plan. During the discussion of treatment options, I have direct eye-to-eye contact, and I’m free to make hand gestures instead of typing into the EMR system. I want to direct all of my energy and attention to my patient, and I think it helps establish a good relationship.

How do you make sure patients really understand?

Dr. Hariprasad: First and foremost, make sure everyone is in the room or on speakerphone at the same time. It’s frustrating to go through an explanation of the surgery, and then have the patient say, “By the way, my wife is in the waiting room. Can I go get her?”

Dr. Wykoff: I prefer to have as many family members as possible in the room. If a patient comes alone, I tell her to please bring family next time. I encourage family members to take pictures of the images on the screen, and they’re welcome to record the discussion if they wish.

When I started my practice, I created another valuable tool: patient-centered handouts. It’s hard to remember what a doctor tells you. It might all make sense in the office, but after patients leave and someone asks a question, they may get confused or not remember the whole explanation. Of course, they can learn a great deal online, but patients like to have something in hand, too. The handouts are just two to four sides of paper with images and plain language explaining common diseases.

I also call patients at home after surgery. Patients often feel anxiety immediately after surgery, and I want to answer questions and assure them that everything went well. Patients want to know that you’re available and can be reached if they have a problem. I thought the phone calls would be a big time commitment, but they average one minute per patient. A typical phone call sounds like this:

“It was good to see you this morning. I’m calling to let you know again that surgery went well and to see if you have any questions.” (Address any questions or issues.) “It’s common for you to have a sense of fullness in the eye tonight. I’ll see you tomorrow morning in clinic.” Occasionally, there are minor issues to deal with, but I’d much rather know about these at 6 p.m. than find out at midnight.

You both have high-level positions. At some point, do you need to delegate some of the patient education to your staff?

Dr. Wykoff: The doctor-patient relationship is of the utmost importance. It’s more important than ever as we get wrapped up so easily in EMR systems and interpreting images. Those things aren’t patient-directed. I need to talk to the patient and family and make sure they understand what I’m thinking and doing.

That said, I view my job as part of a healthcare team, which is the only way to be efficient and effective and have happy patients in modern health care. I wouldn’t be an effective physician without staff to help me get surgical clearance and explain the patients’ steps and restrictions before and after surgery. For patients with macular degeneration, they go over the details of intravitreal injections, including how to prepare the eye and what to do if they have any problems.

Dr. Hariprasad: My surgical coordinator reviews dos, don’ts, medications, times, and instructions for the day of surgery. Any clinical discussion comes from me. Every eye and every retina treatment course is unique. A physician needs to tell a patient that he has a macular hole and explain the surgery. I’m fortunate to have fellows, but many patients come to see me specifically. It wouldn’t be respectful to only have a colleague or staff member speak to them. It can be challenging within our time constraints, but I enjoy the discussion, and it’s how I want to practice. Patients feel engaged and respected, and their positive words travel far. NRP

	Dr. Hariprasad is director of clinical research and chief of the Vitreoretinal Service of University of Chicago, as well as professor of ophthalmology and visual science.
	Dr. Wykoff is director of clinical research at Retina Consultants of Houston, deputy chair of ophthalmology for the Blanton Eye Institute at Houston Methodist Hospital, and co-director of the Greater Houston Retina Research Foundation.