By Dr George L Spaeth
Louis J. Esposito Research Professor
Wills Eye Institute/Jefferson Medical College
Philadelphia, PA, USA
Perhaps the most important key to instructing patients and answering their questions effectively is for the physician to consider himself or herself primarily a teacher and fundamentally interested in educating in the broadest sense of the word. This does not mean “filling up” with so-called “facts” or pieces of medical information. It does mean literally “leading forth.” It means helping the individual control his or her life in a way that will lead to the greatest likelihood that what that particular patient wants will be able to be achieved.
1. Believe everything the patient says. The words may be inappropriate, or even wrong, but underneath the words will be a fundamental truth that the patient is trying to get across to you. It is our responsibility as physicians to translate those words so we can understand that message. And we need to speak back to the patient in ways in which we address that core issue with all the aspects of successful communication: body language, touching, and speaking that is meaningful to the patient.
2. It is essential to be honest. One can be completely honest and yet not be cruel. Lying is almost always disrespectful and arrogant. Remember that a truth can be a lie. A lie is an intent to deceive. “Bullshit” is one of the most venal types of lying, because when we speak bullshit, we fool ourselves at the same time we are trying to fool the patient.
3. Speak in terms the patient can fully understand. Never use abbreviations or jargon. It is deeply disturbing to hear doctors speaking to each other in front of patients about the patients’ CRVO or their decreased MD or the “CME in the OD.” There is no place for such language with patients. Use “the pressure inside your eye,” or “your eye pressure,” rather than “intraocular pressure.” After you have said something to a patient, ask him what he understood you to say. You will be shocked. You think you have said something so clearly that everybody would understand it fully. But when the patient says it back to you, it is a totally different story from what you had in mind. A routine part of communicating meaningfully with patients is asking, “What does X mean to you?” “What did you understand that I just said?”
4. Try to avoid phrases such as, “Unfortunately. . .” or “I am sorry to tell you. . .” Just saying “unfortunately” will turn off the patient’s ability to hear. Simply put the facts out in a way which are understandable, but phrased so as always to leave hope, because there is always hope. It is always, always, always possible to do something that will make the patient’s life better.
5. Do not confuse the patient with the patient’s condition. Do not say, “You are worse.” Rather say, “Your visual field has gotten worse in your right eye.”
6. Always consider the future. Think in terms of a video, not a snapshot. Remember that no treatment of any kind is justified unless you know that without the treatment the patient will have a decrease in quality of life or develop some type of disability. If you cannot be sure of that then there is no justification for starting the treatment, because every treatment causes problems. With that in mind, then, it is easy to instruct the patient to say, “I am starting this drop because without it I believe that you are going to have a decrease in your ability to “X” (drive, read, play tennis, whatever is important to the patient).”
7. Remember that your words and gestures will instruct. For example, when you have measured the intraocular pressure and you say in a definitive, authoritative tone, “Your intraocular pressure is 15,” the patient will conclude that you really know that the pressure is 15. (That is bullshit.) Of course you do not know the pressure is 15 mm Hg. Furthermore, the pressure could easily have been 10 or 20 one hour earlier, or 10 or 30 that evening. On the other hand, if you say something like, “As I measure your eye pressure just now, it is somewhere around 15,” you will be instructing the patient in the difficulty of determining exactly what intraocular pressure the person has. When one looks at the second visual field and says, “Your visual field is worse. You had 4 decibels of loss last time, and you have 8 this time,” the patient concludes that they are twice “as bad” as they were before. Of course that is nonsense. A field change from 4 to 8 decibels may not even be significant. Indicating to patients the softness of all these values is a critically important part of educating them. Everything we do or say educates patients in some way.
8. When you think you have said something especially brilliant, ask the patient what she understood you to say. Then be prepared for a huge deflation. But do not take it negatively. Recognize it as an opportunity to clarify, to engage the patient more fully, to understand the patient better and to have them understand you better so that at the end of the conversation they feel that they have really moved ahead in being able to control their own lives.
9. Finally, remember that your final comments to your patients will remain with them for months or years. Consider a patient who has had a guarded filtration procedure three months before, and at this three-month visit you note that the visual acuity is one line worse, and the person has mild bleb dysethesia, and an intraocular pressure around 12 mm Hg (which is where you wanted it). The parting statement to that patient could be, “I am sorry your eye is so uncomfortable and that your vision is worse. Let’s hope it clears up. It is important that I see you again in six months.” That patient will leave discouraged and will be apprehensive for the entire six months. On the other hand, the parting comments to the same patient could be, “I am very pleased with the result of the surgery. I know that you now have mild irritation, but I also know that you can tolerate that. When the eye feels irritated, blink several times and that will almost certainly make the eye feel better. Your sight is still excellent, and the likelihood is great that you will keep your vision for the rest of your life.” (As you say that you hold their hand and look them directly in the eye, because you are genuinely pleased.) “I am eager to see you again in six months. You are a real inspiration to me.”
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