(1)
St. Johns, FL, USA
(2)
Helen Keller Foundation for Research and Education, International Society of Ocular Trauma, Birmingham, AL, USA
(3)
Consultant and Vitreoretinal Surgeon, Milos Eye Hospital, Belgrade, Serbia
(4)
Consultant and Vitreoretinal Surgeon, Zagórskiego Eye Hospital, Cracow, Poland
Counseling should be the basis of any patient-physician relationship. The more complex the patient’s condition,1 the more complex the relationship and the greater the need for proper counseling. Counseling is a two-way communication,2 during which the VR surgeon provides information to the patient, who then asks questions to clarify what he heard and, finally, makes the final decision regarding treatment – with the surgeon’s help.
Counseling is not easy to master since it is not usually taught in medical school but has a steep learning curve. There is little feedback about the VR surgeon’s progression in mastering it,3 and both the learning of and practicing it are very time-consuming.
5.1 The “Target” of Counseling
The VR surgeon’s life is busy; during the daily routine, it is easy to miss the tree (the branch) for the forest (see Table 5.1) and focus on the tissue or the eyeball, instead of the person.
Table 5.1
Why the indication for surgery should be made by the patient, not by the surgeon
Example | Selected outcome optionsa | Comment |
|---|---|---|
A pregnant woman toward the end of her term presents with full vision in an eye that has 7 D of myopia. Her VA is full but there is a chronic inferior RD, which almost reaches into the fovea. She is unable to determine whether there has been progression lately (the retina has high-water marks) and no documentation is available | If you recommend surgeryb: All may go well: she maintains good vision, and her baby does not arrive prematurely There may be intraoperative complications, the vision remains worse than preoperatively, and her baby arrives prematurely, possibly while she is on the operating table There may be postoperative complications, the vision is severely compromised, her baby arrives prematurely, and the baby is not healthy If you do not recommend surgery: All may go well: she maintains good vision, and her baby does not arrive prematurely Her fovea detaches before the baby is born, in which case: VR surgery is performed, but she still loses some vision It is now too late to operate on the retina because the baby is due, and she loses some or a lot of vision by the time VR surgery becomes possible She loses some vision but before VR surgery could be done the baby arrives prematurely | Options in italics spell some type of disaster for the patient and for the VR surgeon. There will be willing lawyers who try to hold the surgeon legally (and financially) responsible for any imperfection the baby may have if VR surgery was performed and the baby arrived prematurely – or for not having done VR surgery and she loses some vision If it had been the surgeon who talked the patient into surgery (rather than the two of them coming to an agreement based on the patient’s decision), it would be very difficult for him to escape the moral and legal responsibilities should there be any visual loss due to a surgical complication. The surgeon faces the same issues if he decided on his own to decline surgery because he expected no progression of the RD but the fovea nevertheless detaches |
A middle-aged man presents with a macular condition that is typically progressive, likely to destroy the central vision with time. At the moment, however, his vision is almost full and he is not bothered by any symptom. VR surgery is able to prevent the risk to vision, but only if done early | If you recommend surgery: All may go well: he maintains good vision, and he accepts that early cataract development is an unavoidable side effect There may be intraoperative complications, and the vision remains worse than preoperatively There may be postoperative complications, and, despite reoperations, the vision is severely compromised If you do not recommend surgery: All may go well: he maintains good vision forever or at least for an extended period The disease progresses rather fast, and by the time the patient undergoes surgery his vision cannot fully be restored His visual acuity starts to drop, surgery is performed, but intra– or postoperative complications develop and the vision will never be restored to its original level | The risk-benefit ratio must always be the primary, decisive factor determining whether the surgeon agrees to perform the operation (see Sect. 8.1). This is usually a rather straightforward decision if the condition has already caused functional loss. Most people, however, have a great difficulty appreciating the benefits of a prophylactic procedure. If complications occur and the postoperative vision is even slightly worse than the preoperative vision, they will not feel relieved that the surgery prevented the much worse outcome that was likely with “natural history” but feel betrayed by the surgeon who talked them into the operation |
One very often seen example of how some surgeons concentrate on the tissue pathology rather than the person is the way the timing of surgery for a macular hole is determined. A surgeon who declares that “I do not operate on a macular hole until VA drops to 20/40” has no consideration for the individual patient. Several questions immediately come to mind about this:
Why 20/40, and not some other level of VA (e.g., 20/50)?
Indeed, the very fact that there is no consensus about the cutoff VA level shows that such an artificial distinction has no merit.
Is the patient informed that a delay of surgery can cause permanent visual loss?
The lower the initial VA, the smaller the chance of regaining full vision.
Are patients robots so that the same artificially chosen cutoff VA is applicable for everybody?
Some people are extremely bothered by minor visual disturbances while others tolerate much worse ones.4
Pearl
The decision when/whether to operate must not be decided by a random VA value but by the desires of the patient – based on the information he receives from his physician about his condition.
Another example to show the “tissue vs person” thinking is a patient who undergoes cataract surgery and the nucleus is dropped (see Table 9.1). The visual outcomes in the literature are fairly similar whether PPV is performed immediately or delayed by days or even a few weeks.
The cataract or VR surgeon who leaves the timing up to convenience5 looks at the problem on the “tissue level”: since the outcomes are similar, it does not matter when the PPV will be done.
The cataract or VR surgeon who wants the PPV to be done immediately6 looks at the problem as one of a person who expected a complication-free cataract operation with a rapid visual rehabilitation. Now that the complication has occurred, this has all changed, and the patient should not be exposed to days or weeks of anxiety about the final outcome.
5.2 The Patient Does Not Know Most of What Is so Obvious to the Surgeon
Once the surgeon makes the diagnosis, he must inform the patient (and, preferably, his family) about the following:7
The eye’s normal anatomy and physiology. Without this, it is impossible to explain to the layperson what is wrong with the eyeball.
The current condition, describing the pathology that requires a decision whether to treat it.8
The options to choose from. Barring untreatable conditions, there are always at least two choices: do nothing (elegantly called observation or “watchful waiting”) or do something; typically, the “do something” is not a singular option but can be subdivided into several choices.
Briefly, and as appropriate, each surgical procedure should be described.
Presenting the options, the surgeon should try to provide numbers (percentages) for each:9 prognosis, intraoperative, and early and late postoperative complications.10
Counseling is not about one particular tissue lesion only. For instance, if a patient who presents with a macular hole is found to also have a subluxated IOL, he needs to be asked about how much the IOL’s position interferes with his visual functions. If the patient considers it a major hindrance, the VR surgeon should offer repositioning or replacing the IOL during the PPV (see Sect. 38.5.1).
Counseling is not restricted to a preoperative discussion; it may continue intraoperatively if the patient is awake (see Table 15.1) and certainly must continue postoperatively, from “the day after” to the very last follow-up visit.
5.3 Communicating with the Patient
Counseling is not a monologue but a dialogue, even if the surgeon is the “primary speaker”; the patient is encouraged to ask questions and voice comments and concerns. While talking, the surgeon must read his patient’s face and tailor his message according to the patient’s facial expressions.
Q&A
Q
How do you adapt your message or choose your words for that individual patient?
A
Knowing the patient’s educational level and intelligence and whether the patient seems to have common sense is very helpful. The surgeon must also learn to decipher the direct (verbal: the way the patient phrases his questions) and indirect (metacommunication) feedback of how his message gets across. These signals of the latter include, among others, whether the patient’s face reflects understanding or being at a loss and whether the patient’s metacommunication is in agreement with his verbal message.
The surgeon should be able to read the patient’s metacommunication but must also know that most patients will read his own metacommunication. It is crucial for the surgeon not to show contradiction between his verbal message and facial expression, body language, and hand gestures. Even if pressed for time, he should not be caught looking at his watch while the patient talks.
5.4 Coaching vs Trying to Be Objective
By diagnosing the disease, the surgeon knows what his own preferred management option would be. Figure 5.1 helps the surgeon navigate so as to avoid the trap of coaching, unequivocally influencing the patient to choose the surgeon’s preferred option.11
